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GI Coding: Cologuard Insights for ASC Coders

By Paul Cadorette, CPC, COC, CPC-P, COSC, CASCC, Director of Education, nimble solutions
Watch The Anatomy of Coding GI Procedures on demand. Register here.

Gastroenterology is one of the highest volume specialties for ambulatory surgery centers (ASCs). If your ASC relies on this specialty to drive revenue, it’s important to stay updated on CPT codes and payer guidelines, such as documentation requirements and proof of medical necessity.  

What is Cologuard?

Let’s start with the basics. Cologuard is a revolutionary stool-based test designed to detect molecular markers found in cells shed into the intestine in the presence of premalignant neoplasia or colorectal cancer. These markers are present in small quantities within the stool, making it possible for Cologuard to identify the potential presence of premalignant lesions or colorectal cancer. 

Who Qualifies for a Cologuard Test?

According to the CMS National Coverage Determinations (NCD), Cologuard is recommended for patients aged 45 to 85 years who are asymptomatic, meaning they exhibit no signs or symptoms of colorectal disease.  

This test is specifically intended for average-risk patients. Payers may require medical records to confirm that a patient does not have symptoms for colorectal disease and that the patient is not considered high risk.  

It’s essential to note that CMS guidelines regarding Cologuard are often overlooked by practitioners, resulting in situations where patients with symptoms such as rectal bleeding are administered a Cologuard test. In such cases, this test is not appropriate for colorectal cancer screening because the patient is not asymptomatic and exhibits signs or symptoms of colorectal disease. 

Additionally, Cologuard tests are not suitable for patients at high risk. This includes those with personal or family histories of adenomatous polyps, colorectal cancer, inflammatory bowel disease, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer. 

Types of Testing

While Cologuard is the most common GI test, there are other screening options available, including: 

  • Stool based tests: Cologuard (stool-DNA test) and Fecal Immunochemical Test (FIT)  
  • Direct visualization tests: Sigmoidoscopy, or CT Colonography (virtual colonoscopy) 

Positive or abnormal findings on these tests require follow-up with a colonoscopy. 

Follow-up After Positive or Abnormal Findings

A crucial point to remember is that if a patient receives a positive or abnormal result from any of these tests or exams, a follow-up colonoscopy is necessary to fully reap the benefits of screening. A colonoscopy allows for a more detailed examination and potential intervention. 

Patients with positive results are typically eligible for a screening colonoscopy at no cost, unless additional services like biopsies or polypectomies are performed during the procedure.  

In such cases, the patient may be responsible for coinsurance costs related to those services.  

I highly recommend communicating this information to the patient before the procedure to ensure full transparency regarding potential costs.

Coding and Billing

Finally, let’s touch on coding and billing for these services. When a colonoscopy is performed as a follow-on screening after a positive stool-based test result, you should append modifier -KX to indicate this. However, it’s essential to apply this modifier only when no additional findings are present. 

If the physician performs a biopsy or polypectomy during the colonoscopy, you report the appropriate colonoscopy code for the service and append modifier -PT. 

Register for the GI Procedures Coding Course

To learn more about GI Coding, including positive Cologuard tests, eligibility verification, and modifiers, join me on Tuesday, October 17th at 1pm Central for the GI Procedures Coding Course. 

This blog post outlines some of the topics covered in the 2023 GI Procedures coding course, available on demand with corresponding AAPC continuing education units included.

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