Diagnostic vs. Routine Screening Colonoscopy

Erika Stevens, CPC - Senior Professional Physician Coding Specialist Inpatient Coding Leave a Comment

Diagnostic vs. Routine Screening Colonoscopy

Read the first part of this blog, "Coverage for Medicare Colonoscopies" here. 

Average Risk Colonoscopy 

Average risk colonoscopy is defined as a test ordered in the absence of signs or symptoms or other evidence of illness, the physician interpreting the diagnostic test should report the reason of the test as the primary ICD-10 CM code.  The results of the test, if any, may be reported as additional diagnoses. Benefits include reimbursement once every 10 years.   

High Risk Colonoscopy

High risk colonoscopy requires a patient to have a close relative (sibling, parent, or child) who has had colorectal or an adenomatous polyp; a family history of familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer; a personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis.  Benefits include reimbursement once every 24 months. 

Diagnostic Colonoscopy

Diagnostic colonoscopy are for conditions such as, but limited to: melena, chronic diarrhea, blood loss anemia, BRBPR, changes in bowel habits, abdominal pain, positive guaiac fecal occult blood. 

Colonoscopy Modifiers

PT Modifier – Service began as a screening and ended requiring diagnostic intervention due to findings during the screening (biopsy, EMR, polypectomy, etc.).  Only used with federal payers  

33 Modifier – Intent of the procedure is screening.  Only used for commercial payers. 

ICD-10 CM Screening Colonoscopy Codes

Z12.10 – Encounter for screening for malignant neoplasm of intestinal tract, unspecified 

Z12.11 – Encounter for screening for malignant neoplasm of colon 

Z12.12 – Encounter for screening for malignant neoplasm of rectum  


National Correct Coding Initiative (NCCI)

CPT code 45385, flexible colonoscopy with removal of tumor(s), polyp(s), or lesions(s) by snare technique, and column two CPT code 45380, flexible colonoscopy with single or multiple biopsies) is often bypassed by utilizing modifier 59.  Use of modifier 59 with the 45380 is only appropriate if the two procedures are performed on different tumors, polyps, or lesions. 

Control of bleeding is an integral component of endoscopic procedures and is not separately reportable.  For example, if a provider performs endoscopic band ligation(s) by flexible sigmoidoscopy, 45350 or colonoscopy, 45398, control of bleeding is not separately reportable with 45334, flexible sigmoidoscopic control of bleeding or 45382, colonoscopy control of bleeding respectively. 

Only the more extensive endoscopic procedure may be reported for a patient encounter.  For example, if a sigmoidoscopy is completed and the physician also performs a colonoscopy during the same encounter, only the colonoscopy may be reported. 


AMA CPT Assistant Guidance 

There are currently over 115 AMA CPT Assistant Transmittals that related to colonoscopy coding for guidance on how to properly code a colonoscopy.  The transmittals include when it is appropriate to report procedures utilizing different techniques together, what is considered part of the “surgical package” and is not reported separately, and what to do in scenarios where a procedure is aborted or incomplete. 

 For more information on coding, auditing, and cancer registry, check out the MRA website here.




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