Changelog

Three fixes for screening colonoscopy and sigmoidoscopy coding on surgeon claims.

New alert when a Medicare screening code meets a non-Medicare payer. If a claim carries G0121, G0105, or G0104 and the payer is commercial or unknown, the claim is now flagged for review. Most commercial plans and most Medicaid plans expect the CPT code with modifier 33 instead (45378-33 for colonoscopy, 45330-33 for flexible sigmoidoscopy). Some plans do accept the G-codes, so the alert asks you to verify the payer's preventive policy rather than changing the code.

Modifier PT is no longer added to a pure screening. PT tells Medicare a screening converted to a diagnostic or therapeutic procedure. When a claim carries the base diagnostic code (45378 or 45330) with screening intent and no intervention, nothing converted, so PT no longer appears. The existing "use the G-code" alert still fires, and now also covers flexible sigmoidoscopy.

Less alert noise. The "modifier stripped" alert no longer fires when the predicted modifier matches what the payer rules put back. You will only see it when the prediction and the payer rules disagree.

These changes apply to practices with surgeon companion claims enabled.

Some EMRs print the CPT code that was selected when the case was booked. The booked code does not always match the procedure that was performed. A common example is a colonoscopy booked under a polypectomy code when no polyp was removed.

The autocoder now treats a printed code number as scheduling data, not as proof. The words in the record still count, including words in the booking or scheduling area. But the autocoder does not expand a bare code number into its full code description to add details the record does not state.

What you will see differently:

• Surgical codes follow the documented procedure. If the booking shows a polypectomy code but the report documents a diagnostic exam with no polyp removal, the claim carries the diagnostic code.
• Anesthesia codes for GI cases no longer inherit polyp removal or biopsy from the booked code. A screening colonoscopy with no intervention codes as a screening exam, with the correct payer handling for the PT modifier.
• Diagnosis codes tied to an assumed intervention (for example, a colon polyp diagnosis) appear only when the record documents the finding.

What to look out for: claims where the booked code and the documentation disagree now follow the documentation. If a procedure was performed but not documented, the claim will not include it. Ask the provider to complete the record, then resubmit the case.

Reference material now matches the date of service. When the autocoder looks up code reference material while it codes a case, it reads only the reference set for the claim's date of service. CPT references follow the calendar year. Diagnosis references follow the October to September fiscal year. Before this change, a case coded for an earlier date of service could see current year material.

This matters most on back dated work: a claim for a service in a prior year is now coded against the code set that was in force on that date, not against the current one.

What to look out for: back dated cases should select codes that were valid on the date of service. When a case carries no date of service, the autocoder still reads every year, as it did before. If a claim needs the date of service to be right for this reason, confirm the date before you reprocess the case.

Cystoscopy coding is corrected. Before this change, the autocoder sent laser stone cases to the tumor codes.

A laser used on a bladder tumor codes to the tumor codes. Transurethral resection of a bladder tumor with a laser codes to 52234, 52235, or 52240. The code follows the size of the tumor.

A laser used on a stone codes to the lithotripsy codes. Cystoscopy with laser lithotripsy codes to 52353. When a stent is placed at the same session, the case codes to 52356 instead. Placing a stent by itself codes to 52332.

What to look out for: the anesthesia code can change with the surgical code, because the anesthesia code follows the surgical procedure. Review your cystoscopy cases that document a laser after this update, and confirm that the record states what the laser treated. A record that says only "laser used" does not separate tumor work from stone work.