Question 1

How do you handle coding for a screening colonoscopy when a polyp is found and removed (screening converted to diagnostic)?

Accepted Answer

This is a critical distinction. For Medicare, the primary purpose remains screening, but a therapeutic procedure (polypectomy) was performed. We use the appropriate diagnostic procedure code for the colonoscopy with polypectomy (e.g., 45385). Crucially, we append modifier -PT (Colorectal Cancer Screening; converted to diagnostic test) to the code. We also include the screening diagnosis (e.g., Z12.11) as the primary diagnosis and the finding (e.g., D12.6 for benign polyp) as a secondary diagnosis. This ensures the patient benefits from the no-cost-sharing rule for the screening component, and you are paid correctly for the polypectomy.

Question 2

What is the correct coding for a colonoscopy with removal of multiple polyps using different techniques?

Accepted Answer

When multiple polyps are removed, you typically code the colonoscopy with the most extensive procedure performed. For example, if one polyp is removed with hot snare (45385) and another with cold forceps (45380), you would bill only the snare polypectomy code (45385), as it is the higher-valued procedure. If all polyps are removed with the same technique, you still use the single code for that technique, regardless of the number of polyps, unless a specific add-on code exists.

Question 3

How do you handle billing for biologic therapies for IBD, such as infliximab infusions in a GI practice?

Accepted Answer

GI practices administering infliximab (Remicade J1745) or vedolizumab (Entyvio J0896) for Crohn's disease or ulcerative colitis follow the same infusion billing workflow as rheumatology. We code the infusion administration (96413 for first hour, 96415 each additional hour), calculate J-code units from the actual mg administered using the patient's documented weight, and manage the prior authorization process including step-therapy evidence. We track re-authorization dates and alert the clinical team when renewals are needed to prevent infusion interruptions.

Question 4

Can you manage billing for capsule endoscopy, which has different coverage rules than traditional endoscopy?

Accepted Answer

Yes. Capsule endoscopy (91110 for small bowel, 91111 for esophagus) has specific LCD-based medical necessity criteria — typically obscure GI bleeding, suspected Crohn's disease, or evaluation after inconclusive traditional endoscopy. We verify each payer's specific capsule endoscopy coverage criteria before the study, ensure the ordering diagnosis supports the LCD requirements, and obtain prior authorization when required. We also correctly code the professional interpretation service on the date the physician reviews and reports the capsule study recording.

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