Significance of Lesions and Modifiers in Screening or Diagnostics of a Colonoscopy Procedure

If you have a technique that is being used, it does not matter how many lesions that technique is used on. The technique or the CPT code is only coded once. But if you have a different lesion that you use a different technique on, then you can use that second technique.

If you use a technique on a lesion and it doesn't work and then you use another technique on a lesion, you can only bill for the technique that worked. And all of this should be on the documentation.

So now, we know that the U.S. Preventive Services Task Force has this little booklet that you can get that has all of these preventive services.

But the bottom line is that the modifier -23, when it's appended to our preventive service, or to a service, it's telling the payer that this service should be processed without a patient balance because it has been defined as a preventive service.

Mar 31, 2019
Kelly Dennis

Now, it's a CPT modifier. So it theoretically should be applicable for all payers except for Medicare as you will first (assume). But you do want to check with your individual payers because, you know, all payers can also have their own instructions that they choose to work with. So this is to identify a preventive service or a service that meet the preventive criteria based on the book that has the Task Force requirement – the Task Force results in order to have the mandatory writing off of copays and deductibles.

We have our modifier -PT which is where it's a Medicare modifier specific to Medicare, specific to your colonoscopy, specific to when we have a colorectal screening test which leads to a diagnostic test.

So we go in to do the essentials of a screening test and they see a polyp or a lesion or an ulceration or something that they need to biopsy, lasso, use some technique on. The intent was to do a screening test but the screening test has no copay implications but the diagnostic test does.

So we're going to append this modifier in order to have the Medicare patient be excused from their copays and deductibles.

Now, the diagnosis code will match up with the CPT code for the procedure and that kicks us out of having to manipulate our system in order to get the second diagnosis matching up with a procedure code and all the stuff that we did for a couple of years.

Just append the -PT. The system should then know that this diagnostic test that was done, this biopsy that was done on a polyp was intended to be a screening and therefore the patient should not have a responsibility for their copays and deductibles.

Now, as we look at just those two modifiers, what do we do for our commercial insurances? Well, if we think about the difference between screening and diagnostic colonoscopy, we know that there may be (polyp) implications, there may be patient responsibilities from a financial perspective.

So we want to let them know that, again, this was intended to be a screening co – a screening procedure and it turned into something else based on what was visualized. So the recommendation that we see most often is to append both modifiers.

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