[Music] hello we're ready for another cco club webinar great topic today a little shout out i'm seeing everybody in the comments from dallas texas chicago new york providence pennsylvania yay you know so thanks don't forget tell us where you're at uh we like to uh ooh illinois great great so we're going to get started i really enjoy what we're going to talk about today because it's colonoscopies and if you remember it was a recent cco live that we had doc schmidt on who is a gastroenterologist and we talked about colonoscopies before coding them and the documentation and things however we it's been a while and you know codes change and stuff so i thought it would be a good idea to talk about this again anytime you have a particular procedure that you would like us to do in our cco club to kind of expand it maybe give documentation tips on what to look for so that you can abstract faster or coding tips to get to the highest specificity let us know we'll absolutely do that for the cco club and again in our cco club we like to kind of have fun so feel free to ask questions and we'll keep an eye on it as i see more people putting where they're from keep that up thank you let's go ahead and jump in when you look at colonoscopies they're usually done at ambulatory surgery centers now when you have procedures done and an asc versus having them done in a facility proper there are some things a little bit different from the most part the procedures and everything are done the same however the location is different hospitals versus ascs have different guidelines that they follow and the documentation for the most part is going to be the same but there are stipulations for each that have to do with compliance and stuff that we really aren't going to talk about tonight but be aware of that one of the things that you have to understand regarding things like colonoscopies is intent what's the purpose of the procedure that you're doing now colonoscopies can be done for a lot of different reasons one of them is screening i while i was researching this i looked and found out that now i believe screening starts at the age of 45. now last time i had looked it had always been 50 and that's where you start seeing the providers when you go and see your provider and they say when you know have you had a colonoscopy all these preventative medicine things so everybody gets a colonoscopy and it was around 50 women get mammograms men get their prostates checked uh and of course especially if you have diabetes or anything like that you're going to get your eyes checked yearly and so on and so forth and these are preventative quality measures that are tracked well screenings now for colonoscopies it looks like it's about 45 and that if you have high risk that could even change that number but there is a difference between screenings where we're wanting to look and see is there an issue this is more preventative right versus diagnostic oh you came in and there's issues you're having um you're you're having pain you're having melanoma or where there's blood in your stools or suspected blood in your stools you have signs and symptoms of ibs or crohn's disease or they want to check and see if you have that particular organism factor that is going to cause you to to have complications even getting up in to having gerbs and and stuff donna just stated it dropped due to being the sixth highest case or cause of cancer in the united states thank you for stating that uh donna that would make sense and deb said not all insurances cover 45 depends on insurance and i uh that's another true statement as well thank you uh for saying that now of course risk factors will absolutely make a difference terry says how can you code for professional charges for a termed colonoscopy goes to sigmoid okay we're going to mention that i know i mentioned the sigmoid here so we'll we'll look at that now again screening know the difference between a screening and diagnostic they're different colds and we have to have not only the cpt codes but we also have to have the icd codes to back that up right and we don't do procedures without a purpose or a reason now i also want to to tell you that intent is very important now one of the things that we talked to doc schmidt about and i encourage you to go out and look at his youtube channels which is i believe just doc schmidt he does funny videos but he does educational videos for a garage door enterology as well and he was really gracious to come and talk to us for an hour and answer some of the questions that we had about gastric procedures and things we talked about when you have an upper scope you know how far you go down what's the purpose and so on and so forth and when you have a you know colonoscopy how far you go the purpose and why you wouldn't go all the way up to the duodenum you know and so that was that was interesting to explain but if you have intent say it's a diagnostic test and you intended to get to a certain point and you weren't able to do to either the patient wasn't able to withstand the procedure and maybe the anesthesiologist a doctor called it or maybe there was a mass that prevented you from going to a certain point or there was bleeding you started removing pilots or something we couldn't control the bleeding there's all kinds of reasons to do that so you always code to the intended point that you plan to get to and then you use modifiers to backtrack and say hey we plan to do x but we weren't able to do it so we had but we were able to get to this point therefore to tell the rest of the story you'd use modifiers again purpose you know screening or diagnostic is always going to make a difference and second what was the intended outcome or what was the point you were intending to get to if you don't get there for whatever reason you code the intended and then you backtrack and explain it with a modifier or other sources so let's talk about some screening codes first now these are going to be icd codes and that is you always have to have a reason a purpose you cannot do a procedure without you know a cpt code or even a hix fix procedure code for medicare without having a diagnosis code to tell why you're going to do that and if it's a screening well there's nothing wrong with the person so what do you what diagnosis code do you use well there's codes to explain why you would do that z12.11 encounter for screening for malignant neoplasm of the colon this is your basic code why are we doing a colonoscopy well we're screening for cancer colon cancer and to reflect that it's z12.11 now that doesn't mean the patient has cancer that means that we're doing preventative medicine we're going to screen to see if the patient has this if they don't then they get a clean bill of health and they get to wait until a certain point until sometimes it's ten years sometimes it's five years depending on history your age so on and so forth uh when the doctor will have you come back and some payers want you to wait you know if you have a a good screening then they say okay we won't pay for it again until x amount of time another code would be z85.038 personal history of other malignant neoplasm of the large intestine now you don't have cancer right now but you have had something and so we're doing a screening to make sure everything's going okay it's not diagnostic you don't have any signs and symptoms but it's time to do it again or personal history of colonic polyps which is z86.010 again screening not saying that you have it but it's time to go in and look and make sure everything that your health is being maintained and we haven't had any progression of a disease process and then wrapping up z80.0 family history of malignant neoplasm of the digestive organs again if you have a really high prevalence of digestive cancer and therefore you need to have a screening maybe sooner or more often than someone that has never had any uh complications or uh problems and sometimes uh they're just doing it for surveillance as uh baccata yar i'm not sure i'm sure i tortured that name uh prob uh i'm sorry about that but yeah absolutely that's a really really good point we're just doing surveillance that's the right verbiage that was more appropriate to say than what i was saying so let's move on what about hicks fix codes hicks fix codes are just like cpt codes except they're used by medicare to track so these would be medicare codes for screening let's start with g0121 colonoscopy on individual not meeting criteria for high risk so again this patient if you're high risk that puts you in another category as far as medicare is concerned they would want you to do them more often the protocol changes of of course and therefore again we need to be able to code that this patient's not high risk but it's they're a medicare patient they're over 65 it's time for them to have this screening then g0105 is colonoscopy on individual at high risk now there's several reasons to be of high risk and we'll talk about some of those but it would be a good point for you to go out and do research for yourself so it stays in the little gray cells better what would constitute high risk for a colonoscopy for a over 65 year old patient and then a flexible sigmoidoscopy g0104 uh again this is a little bit uh different as they're going up to the sigmoid uh area versus a regular colonoscopy commercial procedure code so these are your regular cpt codes this is going to be for anybody that is you know under 65 uh the we're coding the procedure so the more common ones are going to be four five three seven eight now this is a colonoscopy again we have to remember where are we going colonoscopy it's flexible diagnostic again diagnostic not a screening including the collection of specimen or specimens so that doesn't mean necessarily you have to collect specimens but they almost always do right you could do it by brushing or washing and when performed you can do a separate procedure notice four five three three zero is is pretty much the same thing except it's a sigmoidoscopy so instead of it being the colon it's the sigmoid area know your anatomy know the digestive tract i would say just go ahead and memorize it especially if you're going to be working with an asc these are so incredibly common and it's not that hard to remember the go start at the esophagus and go all the way down to the rectum uh and be able to go back and forth and say what what part is the large intestine what part is the small intestine now i could have given you pictures and graphics of all of that but we've actually um have done that before so you can go out and check out some of the other videos in the club or one of our pearls we'll go into that a little more in depth okay so let's move on screening to diagnostic one of the things and i think maybe a question has already come up that stated okay we go in we do a screening but they find something and if they find something then they're going to address it right there they're not going to say oop man you're full of polyps and some of those polyps don't look so good so we're going to back out and reschedule you absolutely not they're not going to do that they're going to go ahead and just take those things out right take biopsies send them off uh jane said what about tattooing the colon sometimes that is included in the procedure and sometimes it's not but you can read the description on that jane and it'll give you higher specificity of what's included be very careful with areas that are bundled in that's going to be important so let's talk about what you do if you have a screening that you turn into diagnostic because they found some so if they find a polyp or something else a mass pathology i know that when my husband was in his um graduate studies one of the wives of one of his classmates she had had digestive tract trouble a lot and they uh they kept saying oh it's nerves it's this it's that and finally she said just go in and look because i'm in so much pain this nothing has worked and it was it was several years that she went through all of this and we got the call that they were admitting her into the hospitals like what what did they find they weren't even able to do it they went in they started to go in and there was a mass so large and it was cancerous and so they had to go in and do a bunch of resecting and everything and so she'd lived with that pain and so what started out kind of maybe uh to have been a screening was changed to a diagnostic but actually she had signs and symptoms so at that point really it was more of a diagnostic procedure to go ahead and find out hey why are you having all this pain you know um so again if they go in they see something they go ahead and treat it and this is the verbiage you're going to see and you're going to see this in the documentation most likely a screening turned to the diagnostic procedure so therefore you would code it as diagnostic okay and you could use the modifier pt for the colorectal cancer screening test converted to diagnostic test or other procedure or um you could use med uh medicare likes 33 preventative service services um wait no medicare likes pt uh uh preventative services for commercial likes modifier 33 that would be applicable i know somebody asked about that now when a patient has a colonoscopy and they have gastrointestinal issues like my friend then that is a diagnostic procedure now even if the patient qualifies for a screening and the screening cannot be coded if they have symptoms okay so you have to understand what's the difference between screening a screening has to be a screening throughout the whole procedure and diagnostic it's really common for them to go in and find something and go ahead and and do interventions so that's something to to make sure that you pay attention to removals when they're in there they have to remove stuff right so removals how do you code for that now this is the bat technique that we teach and if you uh are in the pack cave or you've had one of our blitzes or you're one of our students then you're very familiar with our bat technique which stands for bubble highlight annotation technique laureen started teaching this back in the 90s and it just grows every year it's a fabulous way to understand the nuances and the descriptions of the codes because it allows your eyes to to see what needs to be focused on in the code description it also is extremely valuable if you're going to be testing we have a lot of people that say that even though they have encoders online they go ahead and they do the bat technique on their cpt manuals every year because it's so beneficial to help them code uh at a higher specificity so they have a better quality in their coding as well as quantity they're able to code faster because their eyes gravitate and they've made personal notes in addition you know if you're out there working that you might make something specific to your practice that you work for but this is how it works everything after the semicolon you highlight and then you underline specific words and for this removal you are going to use separate polyps and lesions and then each method can be reported separately so let's say you have a patient that they uh perform two different types of removals meaning the technique that they use to remove is different now the reason they would do that sometimes is because of what type of polyp or lesion they see some is more effective to be done with a hot biopsy forceps and some are more effective on snare technique but these are your most common now look four five three eight four is hot biopsy forceps notice that all the verbiage is the same colonoscopy flexible they're going to removal of tumor polyp or other lesion doesn't matter really what you're removing the key is it's a colonoscopy it's flexible and hot biopsy forceps for four five three eight four but for four three excuse me four five three eight five it is going to be snare technique now you can imagine if you're testing and you're looking and you notice up here that um they use hot biopsy and they also use snare technique for testing purposes that right there when you look at that code you know that they've got to use two separate codes for that and therefore you can look real quick oh yep they used more than one code to describe the removal so therefore i know that's going to be the you know probably the right answer just a little testing technique for you to tip to help you but just when you're working again if they do more than one type of removal then you could end up with multiple procedure codes being used and if you don't use those one you're screwing up the statistics on how they're taken out and the effectiveness of also the pathology report when it comes back because maybe hot biopsy forceps are more commonly used for a particular type of polyp where snare technique might be used for specific type of lesion so on and so forth but you're not going to get re your provider is not going to get reimbursed for the the work and the complexity of his patient care that he's having to use so documentation let's talk about what words are going to pop on these two codes that we just talked about when you look at the documentation that the provider will be using in the report now it's all about the verbiage when you get to this point and again you already know that they're doing a colonoscopy and that they're removing things right so we've got two codes and this ultimately just kind of talks about how it's done and it will uh let those words pop so main words hot biopsy so if you see the word hot anywhere in a colonoscopy it's probably going to be a hot biopsy so what they do is these forceps they use to remove the lesion and it's actually an insulated monopolar forcep you can go out and look at those and i think we did a video one time a webinar on the different types of snares and biopsy and tools that are used for colonoscopies so that would be a lot of fun to go back and look or just do your own research so again they use electrocauterization or electro co let's see let me say that again electro coagulation in other words they it pulls it off and it cauterizes the uh tissue where they're removing it it helps with the bleeding so on and then um they're used primarily for small polyps or to treat vascular ectesis so again if you see that verbage in the report what they're removing well your knowledge base would say oh yeah they probably used a hot biopsy four step because that's what they usually do but then if you get in it there that op report and you start seeing that the provider is describing a mass of a different type of lesions or polyps then that's a good indication that hey you know what he is probably here she is going to be most likely using multiple ways to remove so heads up right again paying attention to the verbage will make you a better coder so for four five three five excuse me i'm inverting numbers tonight four five three eight five snare loop and again this looks like a loop a little metal wire that loops on the tool so if you were to have like a this is your tool and then there would be a loop on the end of that i think it kind of looks like that little zit tool that you can sometimes get that's got the little wire loop on it anyway of course much bigger but that's kind of the way it looks and that thing will loop around the polyp and then they can squeeze it and pull and just kind of snap that thing off now there are uh different types i think there are some that can be well even states here the loop is heated to shave off and cauterize the lesion so even though the hot biopsy forceps goes and grabs like this and heats up and pulls out whereas the loop is a wire loop that heats up you lay it on there and it you know cauterizes as it goes now they can be done in block with one placement of the stairs snare which is called a piece mult fashion in other words you could have a bunch of polyps right there and they can make this loop and just pull them off all in black multiple order lesions whatever they've got to do they can pull that off kind of in mass i guess might be a way of thinking but they're not going to say that so keywords wire snare loop if you see the word loop that's an indication in block is very commonly used in the verbiage of the documentation that the provider uses and they also like to use this piecemeal fashion i see that used a lot they can do multiple applications of this snare and they just go and grab and yank kind of sizzle them off now uh when they uh pull out the the the scope uh and they're looking at the surfaces they'll look for ulcerations bleeding site lesions strictures and other abnormalities with any time you just do these procedures period okay so uh again that verbiage you'll see that as they're they'll go in and then kind of what they like to do i believe is they they go in they get to the point where they want to go and they kind of look around and then as their back tracking back out that's when they start uh removing these these um procedures doing these removal procedures i may be incorrect but that's kind of the way it sounds when you're reading the the ops so therefore you know that's that's my take we can always ask dr doc schmidt and and see so diagnostic therapeutic procedure codes for colonoscopy flexible just expanded a little a bit more notice those two that we kind of highlighted the verbiage on are there four five three eight four and four five three eight five but this is a list of a a block or where you would bubble around all of these and say okay these are flexible colonoscopies so what makes them different now that that backslash c just means with that's a medical abbreviation that just allows uh well when you wrote it just meant that you could write more we don't write stuff out like we used to in fact i think i keep talking about doc schmick but he was talking about abbreviations on a video the other day and um i had to kind of snicker because he is more of one of my i could be his mother and he you think of his generation in the medical field versus my generation in the medical field we did a lot of writing and we would read providers uh documentation handwritten notes all the time and have to decipher that and and they used to talk about you know how poor handwriting was but when you're writing a hundred of these out every day you know yeah your handwriting gets pretty pretty weird after a while well you use a whole lot more medical abbreviation and some of the things that he mentioned he he said you know talked about not using or he didn't didn't you know particularly care for that abbreviation and i'm thinking yeah because you didn't have to write all that out right now it's all on the computers because we're required to be electronic now but again that is with and if the term without the abbreviation is the the um slash with a a an s not a w but an s for without because it's based on latin all right so four five three eight zero is with biopsy single or multiple so you have a co you have a flexible colonoscopy they're gonna do a biopsy and it doesn't matter if it's one biopsy or multiple you'd use four five three eight zero now four five three eight one's a little different because it's with directed submucosal injection and it's any substance they don't care what you inject in there but you are injecting something submucosal then 45382 is with control of bleeding any method okay and again you can see why you would have to possibly use more than one of these codes then the two we've already talked about four five three eight four and four five three eight five are your two different types of um removal of of uh something they're removals and then four five three eight eight is with ablation of tumor now ablation can be done in all over different parts of the body it can be done in the heart it can be done in the uterus it can be done in the uh you know digestive tract again ablation ultimately means that what you're doing is you're destroying the tissues uh and then they they won't continue to work anymore so the reason they would do that in the heart would be that they're going to you know kind of like blow out one of the parts of the essay or a node so they don't continue to pump in an arrhythmia or something if they do in the uterus it's usually to control bleeding so they they ruin or destroy via ablation weather uh via laser or hot water uh the inside lighting of the uterus and therefore it can't reproduce and then you'd no longer have a mensis okay so here they're going to do with ablation and it includes pre and post dilation and guidewire passage when performed and when that means when performed if they need to use it okay so again just because they do that doesn't necessarily uh uh if they don't do it it doesn't matter you still use that code but they do do it you use that and then 45390 is with endoscopic mucosal resection resection is different because resection has a different term so you're actually resecting and and pulling something out uh agatha asks can you use uh four five three eight one for tattooing um yes i do believe that is considered tattooing uh uh in fact i started to mention it but then i kind of stopped and think wait any substance is this tattooing i can't remember so i was going to kind of not kind of skip over that and not say that however you asked agatha and i think it is but again don't um don't take my word for it go out and double check or ask in the club and we'll uh when you go in there we'll revisit it and we'll find a little more research because i was thinking that tattooing was mentioned in a description somewhere but it can they use tattooing in other parts but for the most part digestive tract so i don't want to mislead you and say yes absolutely but it would be any uh submucosal injection that's submucosal that tattooing so they can they uh okay so deb says yes we use it for tattooing so deb obviously has more experience with this actually drops those codes with what she does thank you deb for saying that so again it was a little bit hesitant like i think it is but you know again even when you are watching webinars and education and stuff if you ever doubt uh something go out and do your own research and make sure because you know we're we're definitely not perfect we're trying to educate you and give you information because it always should be a starting point for you to also educate yourself further and things change all the time all right so let's move move on oh well gosh that was it um did you have any questions since we are still going strong i think i talked a little fast tonight but that's because it's exciting uh you guys had some fabulous questions is what if the doctor documents the reason for the procedure as screening surveillance high risk ulcerative colitis well if they state that they're high risk because that to me would say they've had ulcerative colitis in the past because and so therefore they make them high risk or they're going to keep screening them so again i would use the screening code however if they get in there and yeah sure enough there is a an ulcer or any type of colitis that they say which is an inflammation and stuff then again he's going to probably treat that and and that's when it goes from a screening to a diagnostic so but again pay attention to the um the purpose and uh know that that's important i didn't cover any of um the modifiers but we've done a lot of work recently with modifiers and i know i believe the the interview we did with doc smith we talked about some modifiers so absolutely uh pay attention to those pro profile is the best set of day for colonoscopy at least in my opinion christopher thank you for saying that because um that is pertinent and anesthesia does a different report right that's not in the regular op report anesthesia reports would uh fall under there so thank you christopher appreciate that donna says are there any z codes uh uh always sequence last no no in in this instant when we're dealing with z codes that tell why you're doing a procedure meaning uh they are like encounter codes then they would be listed first so let's say that they did a screening use the screening code and um but they also mentioned that the patient had hypertension well the z code would go before that but you you have to there's multiple reasons for z codes and in this scenario an encounter code reason for encounter they they're usually listed first in the diagnoses sequencing check specific uh insurance policy for us radio colis is high risk some have age limits good point that is true and again uh now some of us are do coding and some of us do billing both and vice versa but you really have to know both worlds and so that's an excellent point uh let's see terry says our doctor has a diagnosis uh sub optimal prep i use uh uh code z91.19 what do you think you know what that that is that's a valid code i can't tell you because i don't have my encoder up if i did i would bring it i would look it up for you but uh even dr schmidt mentioned that they go in and they plan especially a screening and you know really they can't see properly because it was a bad prep sometimes they'll go ahead and just back out and reschedule because what's the use in spending your time when you can't you can't treat what you can't see right so uh again that is a really good point uh terry yes i believe that code sounds familiar and that's the one you would use z 91.19 double check it but excellent now sub optimal prep again dr schmidt said that i encourage you guys to go look uh look him up on youtube and me saying that don't forget that we have a youtube channel medical coding cert some of you may be watching via youtube i can kind of see that you are i can see the little logo would you please help us out by liking this video also subscribing to us and you can hit that little bell and that'll tell you when we're going to put more videos out on youtube we do youtube videos we'll put them out sometimes three times a week predominantly tuesday wednesdays and thursdays sometimes more often but again that would that would help us out and don't forget to share uh we would like to increase our base of people that are following us because feedback tells us that a lot of people find us on youtube don't forget also that you can go to our cco club if you become a member you get access to all of this content plus the transcript and the slide deck so you'll have these codes that you could maybe uh make yourself a flyer and have that at work where these easy codes are set up for you all right i uh uh appreciate you guys staying with us and uh christopher said they're admit i think there's a modifier for that yeah yeah for uh colonoscopy procedures most doctors reach the cecum and perform a biopsy then document that due to poor prep patients should return and um uh yeah absolutely tonya you are right all right i'm glad this was helpful for you and don't worry we'll be back doing this again every week thanks guys do you need more medical certification and business training learn more at www.cco.us [Music]