Examining Colonoscopy Billing

10 Jul

Colonoscopies are an important tool in the diagnosis and prevention of certain cancers. In examining colonoscopy billing for potential Fraud, Waste and Abuse (FWA), there are several areas of potential risk. This article is focused on a very specific area of colonoscopy billing risk that has been observed recently, billing colonoscopies with the control of bleeding. This procedure can often have a much higher payment than other colonoscopies and can be bundled with several other codes as well.

How is it Billed?

44391: Colonoscopy, flexible; with directed submucosal injection(s), any substance

In this procedure, the provider examines the portion of the colon that remains after a colon removal procedure using a colonoscope, a tubular instrument with a light source and camera. The provider inserts the scope through a previously placed colostomy stoma, an opening on the skin of a surgically created passageway into the colon. The provider then identifies and repairs areas of internal bleeding.

45382: Colonoscopy, flexible; with control of bleeding, any method

In this procedure, as with the 44391, the provider examines the colon and rectum using a colonoscope, to identify the source of internal bleeding. He/she then controls the bleeding in the colon by various methods.

Though payment polices can vary, typically, there are two conditions that more often will be the reason for billing this procedure:

  • The patient presented with gastrointestinal bleeding and the colonoscopy is being used to investigate the cause of the bleeding.
  • A patient returns for postoperative care from a diagnostic colonoscopy and bleeding has begun. In such cases, using a modifier 78, return to operating room along with the control of bleeding Current Procedural Terminology code (CPT) is what you would expect to see.

What Should I Look For in the Data?

There are many behaviors you can look for to help you identify potential risk in this area:

  • Is the control of bleeding procedure billed at the same time as a diagnostic colonoscopy? If so, how often? What, if any modifiers are being used?
  • What percentage of the colonoscopy patients are being billed with the control of bleeding CPT?
  • Has the billing of the procedure increased at an abnormal rate? Has it decreased rapidly?
  • Does the provider bill an atypical number of colonoscopies with biopsies, versus those without?
  • Does the provider’s patients return for follow up procedures at unusual frequencies, especially if the initial colonoscopies failed to identify any issues of concern.
  • A provider who exhibits excessive billing of and/or a disproportionate ratio of patients with billing colonoscopies with control of bleeding should be further reviewed.

If you have general SIU questions or comments, please contact us at SIU@hcfraudshield.com.

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