Anesthesiologists who bill for anesthesia services during screening colonoscopies should be aware of required coding differences among various government and commercial payers.
Starting with January 1, 2018, dates of service, anesthesia services furnished in conjunction with screening colonoscopies should be reported to Medicare with CPT code 00812 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy). Medicare will then waive the deductible and coinsurance when paying for the anesthesia service.
When a screening colonoscopy becomes a diagnostic colonoscopy (i.e. if polyps are found), the anesthesia service should be reported to Medicare with CPT code 00811 (Anesthesia for lower intestinal endoscopic procedures, endoscopy introduced distal to duodenum; not otherwise specified) and the PT modifier, indicating the procedure began as a screening colonoscopy. In that case, Medicare will waive only the deductible when paying for the service.
The problem is that Medicare’s use of two CPT codes for screening colonoscopies based on the findings is contrary to the CPT description and rule for those codes.
According to CIPROMS Director of Anesthesia and Ambulance Coding, Teri Jo Alexander, the CPT instructions listed with CPT 00812 say, “Includes Anesthesia services for all screening colonoscopies irrespective of findings.” As such, many commercial payers require screening colonoscopies, regardless of the findings, to be reported with 00812, and only colonoscopies ordered for diagnostic purposes to be reported with 00811.
However, those same commercial payers with Medicare Advantage plans have to follow Medicare guidelines for those members, which means choosing a code for screening colonoscopies based on the findings.
Also, not only are the coding requirements different among payers, so are the way these claims are processed and whether or not the procedure is applied to the patient’s coinsurance and deductible. The following chart shows how the procedures are coded, billed, and processed based on the CPT instructions and Medicare’s instructions.
| Source | Code | Basic Definition | Payer Result | Diagnosis |
| CPT | 00811 | Colonoscopy done for diagnostic purposes. | Procedure applied to deductible and co-insurance. | Various |
| 00812 | Colonoscopy done for screening purposes, irrespective of findings. | If stays preventative, deductible and co-insurance waived. If becomes diagnostic, deductible waived. | Z12.11 or Z80-89 should be primary | |
| CMS | 00811 | Colonoscopy done for diagnostic purposes, or screening purposes with findings. | Procedure applied to deductible and co-insurance, unless billed with PT modifier indicating it began as a screening procedure, then deductible waived. | Z12.11 or Z80-89 if began as a screening procedure. |
| 00812 | Colonoscopy done for screening purposes if no findings. | Deductible and co-insurance waived. | Z12.11 or Z80-89 should be primary |
For more information about Medicare’s coding and billing guidelines for anesthesia during screening colonoscopies, review our recent article, Billing Anesthesia Services for Screening Colonoscopies to Medicare. For more details about the CPT coding instructions, consult the 2018 CPT code set in a print or online edition. Also, providers should monitor payer EOBs carefully when billing for these procedures to be sure payers respond as expected and that patients are not left with unnecessary charges applied to their deductible or coinsurance.
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