What is the modifier for screening colonoscopy turned diagnostic?
Asked by: Kadin Rolfson V | Last update: February 5, 2025Score: 4.5/5 (47 votes)
How do you bill a screening colonoscopy turned diagnostic?
If a polyp or lesion is found during the screening procedure, the colonoscopy becomes diagnostic and should be reported with the appropriate diagnostic colonoscopy code (45378-45392). For Medicare patients, the PT modifier would be appended to the code to indicate that this procedure began as a screening test.
When to use modifier 33 for colonoscopy?
CPT® developed the 33 modifier for preventive services, for “when the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or ...
When to use modifier 53 for colonoscopy?
The failed procedure is billed and paid using CPT® code 45378, HCPCS code G0105 or G0121, or CPT® code 44388, if attempting to perform the colonoscopy through an existing stoma. Modifier “-53” (discontinued procedure) must be appended to any procedure code submitted when billing for a failed colonoscopy attempt.
What is the modifier 22 for a colonoscopy?
When the colonoscopy procedure is unusual or difficult, modifier 22 (unusual procedural services) may be reported. The most specific ICD-10-CM code must be chosen and billed to its highest level of specificity. Submit this as the line diagnosis (linked to the procedure) on the claim.
Colonoscopy - Screening, Diagnosis, and Surveillance for Colon Cancer
What is the modifier for a diagnostic colonoscopy?
The –PT modifier indicates a screening colonoscopy has been converted to a diagnostic test or other procedure.
What is a 22 modifier used for?
Modifier -22 is to reflect additional work that is not typically part of the procedure, but does not qualify for its own procedure code. Depending on the documentation submitted, JHHP may or may not allow additional reimbursement.
What is the modifier 52 for colonoscopy?
Therapeutic colonoscopies that are incomplete (the scope does not reach the cecum during a therapeutic procedure) are reported with modifier 52. It is important to note that the codes for reporting these procedures differ between Medicare and other payors.
What is the difference between screening and diagnostic colonoscopy?
While screening colonoscopies are key to catching problems in their earliest stages before symptoms arise, a diagnostic colonoscopy is necessary when symptoms are already present. Screening or diagnostic approaches are even more important if you have a personal risk of colorectal cancer or certain medical conditions.
Why is a diagnostic colonoscopy not covered by insurance?
Soon after the ACA became law, some insurance companies considered a colonoscopy to no longer be just a “screening” test if a polyp was removed during the procedure. It would then be a “diagnostic” test, and would therefore be subject to co-pays and deductibles.
What is the DX code for screening colonoscopy?
2025 ICD-10-CM Diagnosis Code Z12. 11: Encounter for screening for malignant neoplasm of colon.
What is the 33 modifier used for?
Modifier 33 is used to tell the payer to process the service without a patient due balance, because it was a preventive service with an A or B rating from the USPSTF. Not all commercial patients will have this first-dollar coverage, but many with group health insurance plans will.
When to use modifier 95?
-95: Synchronous telemedicine service rendered via a real-time interactive audio and video communications system.
When to use kx modifier for colonoscopy?
Modifier KX was published in Medicare's Med-Learn Matters Article, MM13017, addressing modifier KX. Medicare indicates the following: "Attach the KX modifier to a screening colonoscopy code to indicate such service was performed as a follow-up screening after a positive result from a stool-based test.”
How do you get a diagnostic colonoscopy?
You will likely need to make an appointment with your primary care doctor so that he or she can determine if you need a colonoscopy and order the procedure if appropriate. A gastroenterologist is a doctor who specializes in treating conditions of the gastrointestinal system and is trained to perform colonoscopies.
Does Medicare pay for diagnostic colonoscopy?
Medicare covers screening colonoscopies once every 24 months if you're at high risk for colorectal cancer. If you aren't at high risk, Medicare covers the test once every 120 months, or 48 months after a previous flexible sigmoidoscopy. There's no minimum age requirement.
How to bill screening colonoscopy turned diagnostic?
One or more polyps may be removed at the time of a screening colonoscopy. Since the procedure was initiated as a screening, the screening diagnosis is primary and the polyp(s) is secondary. The appropriate code (CPT code 45379—45392) should be reported for the diagnostic or therapeutic procedure performed.
What is the difference between screening and diagnostic?
Screening tests are primarily used for early detection of disease or risk factors whereas diagnostic tests are used to establish the presence or absence of disease. Screening tests are often done among people without symptoms who may have a higher risk of developing disease.
Does Medicare accept modifier 33?
Claims submitted to Medicare containing modifier 33 will be returned with Medicare Outpatient Adjudication (MOA) code MA130, which indicates that the claim contains incomplete and/or invalid information that is “unprocessable.” As such, you should only append modifier 33 for non-Medicare payers, as per AMA instructions ...
When to use modifier 52 or 53?
I. Modifier -52 is used to report “reduced services.” II. Modifier -53 is used to report “discontinued procedure.” (For outpatient/ASC facility charges, see Coding Policy 39.0.)
What is modifier 62 used for?
Two surgeons. Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session.
What are examples to use modifier 52?
Example One
A provider performs a unilateral tonsillectomy for a ten-year-old patient (CPT code 42820). In this case, apply modifier 52. This CPT assumes bilateral surgery, so to show that it was only performed on one side, or electively reduced, modifier 52 would be appropriate.
What is the modifier 22 for colonoscopy?
If so many polyps were removed that the procedure took significantly longer than usual, you can append the modifier 22. You must submit the procedure report as well as a statement indicating why the procedure took so much longer and how much longer it took.
What is the 59 modifier used for?
Modifier 59 Distinct Procedural Service indicates that a procedure is separate and distinct from another procedure on the same date of service. Typically, this modifier is applied to a procedure code that is not ordinarily paid separately from the first procedure but should be paid per the specifics of the situation.
What is a 25 modifier used for?
Modifier 25 is appended to indicate that a significant, separately identifiable E/M service was performed by the same physician or other QHP on the same date.