ICD-10-CM Diagnosis Coding

Z12.11, screening for malignant neoplasm of the colon is used as the principal diagnosis when the physician documents that the colonoscopy is being performed for screening for neoplasms in large intestine and is documented as follows:

  1. Screening for colon carcinoma on patient with personal or family history of colon carcinoma.  Add the appropriate history codes if the condition has been eradicated.  Any findings new or recurrent are listed as secondary diagnosis codes.
  2. Screening colonoscopy that has been converted to a therapeutic exam: in cases where a biopsy or polypectomy is performed, Z12.XX is still listed as the principal diagnosis.  List the findings as secondary diagnoses.
  3. A past history of polyps and patient is being screened again for polyps:  Z12.XX is listed as the principal diagnosis if the findings are negative.  Z86.010 personal history of polyps, is listed as a secondary diagnosis code.

Screening for malignant neoplasms:

Z12.1 is the category for the screening for cancerous neoplasms of the intestinal tract.

Report:

Z12.10 for screening of unspecified intestinal tract

Z12.11 for screening of colon

Z12.12 for screening of rectum

Z12.13 for screening of small intestine

 

Symptoms as Principal Diagnosis 

If the reason for the colonoscopy is a symptom such as abdominal pain, bleeding, change in bowel habits or other colorectal abnormality, and the endoscopic finding is negative, list the symptom as the principal diagnosis. This only applies to symptoms that are not stated as probable, possible or rule out, in the outpatient encounter. If the postoperative diagnosis is different than the admitting diagnosis, report code for the postoperative diagnosis as this is in accordance with ambulatory surgery guidelines.

If any symptoms or known active gastrointestinal diseases are listed as the reason for the colonoscopy or sigmoidoscopy, it is not considered a ‘screening exam’ and therefore the screening exam diagnosis code (Z12.11) and G code are not reported.

When a symptom is listed as the reason for any examination, it  makes the procedure a diagnostic examination and therefore the screening exam diagnosis codes (Z12.11) and procedure codes (G0121) are not reported.

Examples:

  • If the patient has an exam due to rectal bleeding, but a normal exam was found. The reason for the exam is still rectal bleeding, because it caused the admission.
  • If the physician states rectal bleeding and the exam found external hemorrhoids; external hemorrhoids would be reported on the outpatient encounter, because it is the most ‘definitive’ diagnosis. The rectal bleeding diagnosis should be listed as a reason for visit diagnosis, i.e. admitting diagnosis, on the outpatient hospital encounter as well as a secondary diagnosis, unless the physician states the cause of bleeding was related to hemorrhoids. The coder should not assume a cause and effect relationship between the two conditions.

Coding Polyps

Polyps are identified by the site and morphology, i.e. adenomatous.  A benign neoplasm of the ascending colon is reported, D122, whereas a benign neoplasm of the sigmoid colon is reported with D125.  If a polyp is stated as being ‘hyperplastic’ report K635.  Code all sites and morphologies that are specified.

Obstructed Exams

When a patient is admitted for a screening, diagnostic or therapeutic exam and the scope is unable to proceed due to obstruction or complication the endoscopy exam is coded the following criteria:

  • If the scope does not reach splenic flexure report sigmoidoscopy exam.
  • If the scope goes beyond the splenic flexure but not to the cecum, report colonoscopy exam with modifier 53.
  • If the scope goes beyond the splenic flexure but not the cecum, and a therapeutic exam such as a biopsy was performed use modifier 52.

Example:

  • If a patient is admitted for a screening colonoscopy and the patient had extensive diverticular disease in the sigmoid colon which was biopsied, but the colonoscope was unable to reach the splenic flexure, the therapeutic exam would be reported would be a sigmoidoscopy with biopsy 45331-PT.    No modifier for reduced service would apply because the sigmoidoscopy was carried out with biopsy. It may not have been the intended procedure, but the CPT reported was completed, therefore no modifier is necessary.
  • If a patient is admitted for a therapeutic exam with a known stricture in the cecum to be dilated however the exam had a poor prep and the scope did not reach the cecum but went beyond the splenic flexure. It would be reported as a diagnostic colonoscopy with a reduced service modifier; 45378-53.

Control of bleeding

Endoscopic exams that state ‘control of bleeding’ should not be assigned when the bleeding was a direct cause of the procedure performed.  For instance, if a patient had a polyp removed and the bleeding was a direct result of the polyp removal, controlling the bleeding is considered integral to the procedure.

If the patient has bleeding from a vascular malformation that requires cautery because of continuous bleeding and is not also biopsied. This would be reported. If a site other than the bleeding site is biopsied, report the control of hemorrhage code with a modifier 59(XS).

In ICD-10-PCS codes are dependent on the method used to control the bleeding; therefore many different ICD-10-PCS codes can substantiate one CPT code.

Cauterization and ablation see ‘destruction

Ligation sees ‘occlusion

Injection see ‘introduction of other therapeutic substance

 

Colonoscopy (45378-45398)

ICD-10-PCS for screening or diagnostic exams

Inspection of Lower intestinal tract, via natural or artificial opening endoscopic

 

45385 – Colonoscopy with snare polypectomy

ICD-10-PCSExcision, by site, via natural or artificial opening endoscopic with a diagnostic qualifier.

45388 – Colonoscopy with ablation of tumor, polyp or other lesion including dilation and guidewire when performed

ICD-10-PCS– See Destruction, by site, via natural opening endoscopic

45389 – Colonoscopy with a stent placement including dilation and guidewire when performed.

ICD-10-PCS If the stent remains it would be reported in ICD-10-PCS as Insertion, by site, with intraluminal device, via natural or artificial opening and/or Dilation, by site, with intraluminal device, via natural or artificial opening.  If the stent is removed at the end of the procedure report  ICD-10-PCS, it would be reported as Dilation*, by site, via natural or artificial opening, no device     *as long as documentation supports dilation.

45390 – Colonoscopy with mucosal resection includes biopsy, polypectomy or band ligation of the same lesion.

ICD-10-PCS Excision by site, via natural or artificial opening endoscopic, diagnostic

45393 – Colonoscopy with decompression; includes placement of a decompression tube.

ICD-10-PCS Release by site, via natural or artificial opening endoscopic.  If the tube remains it would be insertion of intraluminal device, via natural or artificial opening.

45398 – Colonoscopy with band ligation, includes control of bleeding diagnostic colonoscopy, and may not be reported more than once per episode.

ICD-10-PCS See Occlusion, by site

45399 – Unlisted procedure, colon is reported when procedure performed does not have a specific CPT code available to support the services performed.

ICD-10-PCS would be determined by the actual procedure performed.

 

Screening sigmoidoscopy

Report code G0104 for any colorectal cancer screening using flexible sigmoidoscopy for CMS patients and payors following CMS guidelines. Report screening code as the first listed diagnosis; Z12.XX range.

ICD-10-PCS for screening or diagnostic exams

Inspection of Lower intestinal tract, via natural or artificial opening endoscopic

 

Sigmoidoscopy (45330-45350)

45346 is a sigmoidoscopy with ablation of tumor or polyp, including dilation and guidewire passage.

ICD-10-PCS– See Destruction, by site, via natural opening endoscopic

45340 is a sigmoidoscopy with transendoscopic balloon dilation of stricture. If more than one area is dilated report each additional area treated with a modifier XS.

ICD-10-PCS– See Dilation, by site, via natural or artificial opening endoscopic

45341 is a sigmoidoscopy with an endoscopic ultrasound exam.

ICD-10-PCS– See Imaging, gastrointestinal system, ultrasonography

45342 is a sigmoidoscopy with ultrasound guided intramural or transmural  FNA/biopsy or aspiration.

ICD-10-PCS– See Imaging, gastrointestinal system, ultrasonography and Drainage or Excision, by site, via natural or artificial opening endoscopic, diagnostic

45347 is sigmoidoscopy with a stent including dilation pre and post application of stent.

ICD-10-PCS If the stent remains it would be reported in ICD-10-PCS as Insertion, by site, with intraluminal device, via natural or artificial opening and/or Dilation, by site, with intraluminal device, via natural or artificial opening.  If the stent is removed at the end of the procedure report  ICD-10-PCS, it would be reported as Dilation*, by site, via natural or artificial opening, no device     *as long as documentation supports dilation.

45349 is a sigmoidoscopy with a mucosal resection is defined by site.

ICD-10-PCS Excision by site, via natural or artificial opening endoscopic, diagnostic

45350 is a sigmoidoscopy with band ligation of hemorrhoids.

ICD-10-PCS See Occlusion, by site

Stomal endoscopy 44380-44408

44388 is a diagnostic colonoscopy through a stoma.  The same rules apply when reporting a screening exam; G0105 (high risk), and G0121(non-high risk) for screening colonoscopy through stoma are used if the criteria above are met.

ICD-10-PCSInspection, lower gastrointestinal tract, via natural or artificial opening endoscopic

44389 is a colonoscopy through a stoma with biopsy

ICD-10-PCS Excision by site, via natural or artificial opening endoscopic, diagnostic

44390 is a colonoscopy through a stoma for removal of foreign body

ICD-10-PCS see Extirpation of matter by site, via natural or artificial opening

44391 is a colonoscopy through a stoma for control of bleeding

In ICD-10-PCS are dependent upon the method of control.

Cauterization and ablation see ‘Destruction’, by site, via natural or artificial opening endoscopic

Ligation sees ‘Occlusion’, by site, via natural or artificial opening endoscopic

Injections see, ‘Introduction of other therapeutic substance’, by site, via natural or artificial opening endoscopic

44392 is a colonoscopy through a stoma with polypectomy or removal of tumor by hot biopsy forceps

In ICD-10-PCS see ‘Excision’, by site, via natural or artificial opening endoscopic, diagnostic

44401 is a colonoscopy through a stoma with ablation of polyps, or tumors, not amenable to removal by hot biopsy forceps, cautery or snare technique.

In ICD-10-PCS see Cauterization and ablation see ‘destruction’, by site, via natural or artificial opening endoscopic

44394 is a colonoscopy through a stoma with polypectomy or removal of tumor by snare technique.

In ICD-10-PCS see ‘Excision’, by site, via natural or artificial opening endoscopic, diagnostic

Submucosal Injection

CPT:  Occasionally an injection is required to mark a spot in the colon, or for another therapeutic purpose.  Examples of a substance that may be injected includes India ink, botulinum toxin, saline, and corticosteroid solutions.  The injection is coded only once no matter how many are performed during the same encounter.

ICD-10-PCS:  Check for  introduction of other therapeutic substance into lower gastrointestinal tract.