2018 GI Changes
To receive maximum reimbursement in 2018 for GI cases, it is imperative that you provide as much documentation as possible. Originally CMS and the AMA were following the guidelines outlined below. A colonoscopy that starts as a screening colonoscopy no matter what also transpired in the case, would only be reimbursed at the 3 unit base. Our sources are telling us that the AMA will continue to follow
these guidelines which many commercial carriers use to set their policy.
these guidelines which many commercial carriers use to set their policy.
However, CMS changed their ruling and will allow providers to bill for a Medicare patient that has a colonoscopy that starts as a screening and ends up being diagnostic or therapeutic with the higher base unit code. To do this, RCM will need the pre and post diagnosis to justify the coding.
| 2018 – New Code | 2018 – CMS Base Units Published in Final Rule |
Current Code | 00812 – Colonoscopy- Screening |
Impact To Practice |
|
|---|---|---|---|---|---|
| 00731 – Routine EGD’s | 5 | 00740 | 5 | No impact | |
| 00732 – ERCP’s | 6 | 00740 | 5 | Additional 1 unit | |
| 00811 – Colonoscopy – Non-screening |
4 | 00810 | 5 | Loss of 1 unit | |
| 00812 – Colonoscopy- Screening |
3 | 00810 | 5 | ||
| 00813 – Combine EGD w/Colonoscopy |
5 | Either 00740 or 00810 |
5 | No impact |
The following documentation is very important for proper coding in 2018:
- Screening defined – “a service performed on a patient in the absence of signs or symptoms.”
- It is required to code all colonoscopies that start as a screening with a primary DX code of
screening colonoscopy. If there is a high risk for the screening (e.g. family history of colon
cancer) that would be a secondary DX code. The claim would be paid at the 3 base units and the
same would go for a screening colonoscopy with findings. The primary DX code is screening and
the secondary or tertiary DX codes would be the findings. This too, would be paid at the 3 base
units. - Non-screening colonoscopies are allowed a 4 unit base but must be justified with
documentation. - Dual procedures (EGD/colonoscopy) has a 5 unit base – it is required that a DX code for each
procedure be included. - It is also important to document the Medical Necessity for Anesthesia – patient co-morbidities
(e.g. sleep apnea, obesity, failed moderate sedation).
| 2018 – New Code | 2018 – CMS Base Units Published in Final Rule |
Current Code | Current Base Units |
Impact To Practice |
|---|---|---|---|---|
| 00731 – Routine EGD’s | 5 | 00740 | 5 | No impact |
| 00732 – ERCP’s | 6 | 00740 | 5 | Additional 1 unit |
| 00811 – Colonoscopy – Non-screening or Colonoscopy starts as screening and ends as diagnostic or therapeutic |
4 | 00810 | 5 | Loss of 1 unit |
| 00812 – Colonoscopy- Screening |
3 | 00810 | 5 | Loss of 2 units |
| 00813 – Combine EGD w/Colonoscopy |
5 | Either 00740 or 00810 |
5 | No impact |