The topic of scout endoscopies is one that comes up often for coders in all different specialties because surgeons often perform these procedures during non-endoscopic procedures in the chest, abdomen, and pelvis to help them visualize the organs/structures they are working on or ensure successful completion of their procedure. Distinguishing a diagnostic endoscopy from a scout endoscopy can be difficult at first, but fortunately, we have some guidelines that can help us.
In the NCCI Policy Manual which is published each year by the Centers for Medicare & Medicaid Services (CMS) a “scout endoscopy” is defined a couple of different ways. The first definition we see for a “scout endoscopy” is a type of endoscopy that may be performed before a non-endoscopic surgery:
A “scout” endoscopy to assess anatomic landmarks or assess extent of disease preceding another surgical procedure at the same patient encounter is not separately reportable. – NCCI Policy Manual, Chapter 6, section C.6
Based on this guideline, if the endoscopy is performed at the start of a planned non-endoscopic procedure to assess the extent of known disease, you may not report the endoscopy separately. While the guideline I have provided here is from Chapter 6 which is for the CPT codes in range 40000-49999, this same guideline also appears in Chapter 5 and Chapter 7 of the NCCI Policy Manual which cover codes in range 30000-39999 and 50000-59999 respectively. With that said, this guideline impacts all open and minimally-invasive procedures (e.g., laparoscopic/thoracoscopic procedures) performed on organs/structures in the chest, abdomen, and pelvis, making this a very broadly applicable guideline. So what exactly does “assessing extent of disease mean” and how is this different from performing a diagnostic endoscopy to determine if a patient has disease of an organ/structure and what to do about it? Some examples are included below to help you better understand this guideline and distinguish this type of “scout endoscopy” from a diagnostic endoscopy. Please note the examples below are certainly not an all inclusive list of examples in which an endoscopy would bundle as a “scout endoscopy” to assess extent of disease, but again the examples are provided to help you understand the concept and flag “scout endoscopies” when you see them:
- A patient with a known cancerous mass in the sigmoid colon has a sigmoidoscopy before a planned open colectomy to visualize the location of the tumor and plan the exact location where the colon will be cut to ensure the cancer is removed completely. Because the endoscopy is performed to “assess the extent of disease” (in this case the exact location where the known tumor ends), this is a scout endoscopy and the sigmoidoscopy would not be billed.
- A patient with a known paraesophageal hernia and GERD has a flexible esophagoscopy at the start of a planned hiatal hernia repair and fundoplication to determine how much of the stomach is herniated into the chest cavity. Because the surgeon already knows the patient has a paraesophageal hernia and has already planned to repair the hernia and is performing this endoscopy to determine the severity of the hernia (i.e., how much of the stomach is up in the chest as a result of the hernia), this endoscopy is “scout endoscopy” to “assess extent of disease” and the flexible esophagoscopy would not be billed.
- A patient who has right upper lobe lung cancer has a bronchoscopy at the start of a planned thoracotomy and lobectomy of the lung to determine if the tumor has invaded into the middle lobe or bronchus. Because the surgeon already knows the patient has right upper lobe cancer and is performing the bronchoscopy to see if the cancer has invaded into surrounding lobes of the lung or the bronchus, this endoscopy is a “scout endoscopy” performed to “assess extent of disease” and the bronchoscopy would not be billed.
Another definition for “scout endoscopy” is found in this same section of Chapter 6 of the NCCI Policy Manual, and describes an endoscopy that occurs after a non-endoscopic surgical procedure:
If an endoscopic procedure is performed at the same patient encounter as a non-endoscopic procedure to ensure no intraoperative injury occurred or verify the procedure was performed correctly, the endoscopic procedure is not separately reportable with the non-endoscopic procedure. – NCCI Policy Manual, Chapter 6, Section C.6
Based on this guideline, endoscopies performed to verify that the procedure was a success and the surgeon didn’t cause an unintentional injury during the surgery are also considered “scout endoscopies” and may not be billed separately. As we saw with our “scout endoscopy” before a non-endoscopic surgical procedure, while the guideline I have provided here is from Chapter 6 which is for the codes in range 40000-49999, this same guideline also appears in Chapter 5 and Chapter 7 of the NCCI Policy Manual which cover codes in range 30000-39999 and 50000-59999 respectively. Therefore, this guideline would also apply to all open and minimally invasive (e.g., laparoscopic/thoracoscopic) procedures performed on organs/structures of the chest, abdomen, and pelvis.
Below are some examples of “scout endoscopies” that may be performed after completing a non-endoscopic surgical procedure. This again is not an all-inclusive list but instead provides examples to help illustrate this rule and help you better understand when an endoscopy performed at the end of a surgery would bundle:
- A patient undergoing a laparoscopic gastric sleeve procedure for weight loss has an EGD at the end of the procedure to ensure the staple line for the gastric sleeve is intact and there is no leakage of gastric contents into the surrounding abdomen. Because the procedure is performed to ensure that the gastric sleeve is intact and that this procedure was successful, the EGD would be considered a “scout endoscopy” and may not be billed.
- A patient undergoing a laparoscopic hysterectomy has a cystourethroscopy at the end of the case to make sure the bladder and ureters are intact and no accidental laceration of these organs occurred during the hysterectomy procedure. Because this cystourethroscopy was performed to ensure no intraoperative injury occurred to the bladder/ureters, this is considered a “scout endoscopy” and the cystourethroscopy may not be billed.
- A patient undergoing a planned tracheostomy has a flexible laryngoscopy performed at the end of the procedure to ensure the tracheostomy tube is in appropriate position to allow proper ventilation. Because the laryngoscopy is performed at the end of the procedure to ensure a successful procedure (in this case appropriate placement of the tracheostomy tube), the laryngoscopy is considered a “scout endoscopy” and may not be billed.
To point, we’ve talked about a lot of scenarios in which an endoscopy is not billable with a non-endoscopic procedure, and you may find yourself wondering if an endoscopy can ever be billed during a non-endoscopic procedure. The answer to that question is yes, and fortunately, the NCCI Policy Manual gives us some additional guidance about how to determine when an endoscopy is truly diagnostic. Going back to our same section of the NCCI Policy Manual, Chapter 6, section C.6, we find this guideline:
However, an endoscopic procedure for diagnostic purposes to decide whether a more extensive open procedure needs to be performed is separately reportable. In the latter situation, modifier 58 may be utilized to indicate that the diagnostic endoscopy and more extensive open procedure were staged procedures.
Based on this guideline, if a surgeon documents performing an endoscopy before a non-endoscopic procedure and the findings during that endoscopy result in a decision to perform a more extensive open or minimally-invasive non-endoscopic procedure, you may report the endoscopy and add modifier 58 to your open/minimally-invasive surgical code to indicate the two procedures were staged. This tells the payer that the results of the diagnostic endoscopy were needed to make a surgical plan on how or if to proceed with additional procedures.
As with our scout endoscopy guidelines, this same guidelines about billing diagnostic endoscopies used to determine the need to perform an open or minimally-invasive non-endoscopic surgical procedure is also found in Chapter 5 and Chapter 7 of the NCCI Policy Manual, covering codes 30000-39999 and 50000-59999 respectively. So this guideline also applies to all open and minimally-invasive procedures on organs/structures of the chest, abdomen, and pelvis.
Let’s look at a few examples of diagnostic endoscopies performed during a non-endoscopic surgical procedure:
- A patient presents for a diagnostic bronchoscopy due to a three day history of hemoptysis. The physician performs a flexible bronchoscopy to confirm or rule out disease in the bronchi/lungs. The trachea and bilateral bronchi are examined. The trachea and right bronchi findings are normal, but on the left, the surgeon sees an infiltrating tumor around the bronchus of the left upper lobe. He decides to go ahead and perform a VATS wedge biopsy of this lobe of the lung during the same encounter to rule out malignancy. The VATS wedge biopsy and the bronchoscopy would both be billed because the bronchoscopy was diagnostic (he completely examined the trachea and both bronchi) and the findings of the bronchoscopy (the infiltrating tumor) were needed to determine that the non-endoscopic procedure (the VATS wedge biopsy of the lung) was needed to rule out malignancy.
- A patient presents with a one week history of hoarseness and stridor. A flexible laryngoscope is inserted through the transnasal approach and the nasal cavities, pharynx, and structures of the larynx including the vocal cords/folds are examined. The laryngoscopy reveals a mass in the hypopharynx causing 70% obstruction. Due to concerns about airway compromise, the surgeon steps out and discusses the finding with the patient’s wife and obtains consent to perform transoral excision of a portion of the mass for tissue diagnosis and ablation of remaining tissue to open up the airway. After obtaining consent, the surgeon then proceeds with biopsy and destruction of tissue through a transoral approach. In this case, because the findings of the laryngoscopy resulted in the decision to perform the biopsy/ablation of the mass, both the laryngoscopy and the destruction of the mass would be billed.
I hope these examples help you as you navigate the challenge of determining if endoscopies are scout or diagnostic scopes. If you don’t have a copy of the NCCI Policy Manual downloaded, I encourage you to download a copy from the CMS website and check these guidelines out for yourself: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html . When you get to the CMS website, click on the link for the “NCCI Policy Manual for Medicare Services – Effecitve January 1, 2019” at the bottom of the page. This will allow you to save a copy of the NCCI Policy Manual for yourself and start applying these guidelines about scout endoscopies as well as a host of other helpful topics to your daily coding.
