Medicare Benefits Schedule - Note TN.8.293

Endoscopic mucosal resection (EMR) item 32230 is inclusive of the colonoscopy service described in items 32222, 32223, 32224, 32225, 32226 and 32228.

There is a same day, same provider, same patient restriction with claiming any of the colonoscopy items 32222, 32223, 32224, 32225, 32226 and 32228 with item 32230.

Scenario 1

Should identification of a polyp >= 25 mm occur at time of colonoscopy and the provider is sufficiently skilled and the location of the procedure (facility) appropriately resourced, the polyp may be removed (resected) in situ at time of initial colonoscopy provided adequate consent was obtained by the endoscopist before the procedure.

Where this is the case, the provider will no longer bill a colonoscopy item 32222, 32223, 32224, 32225, 32226 or 32228, rather they will bill item 32230.

Scenario 2

Where the provider is unable to remove the polyp/s >=25 mm, and the patient is required to return to have the polyp removed, then the initial procedure identifying the polyp and thus the need for EMR would be billed to either 32222, 32223, 32224, 32225, 32226 or 32228 and the subsequent resection procedure to 32230.

Related Items: 32222 32223 32224 32225 32226 32228 32229 32230

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Multiple Operation Rule

Endoscopic examination of the colon to the caecum by colonoscopy, for a patient:

(a) following a positive faecal occult blood test; or

(b) who has symptoms consistent with pathology of the colonic mucosa; or

(c) who has anaemia or iron deficiency; or

(d) for whom diagnostic imaging has shown an abnormality of the colon; or

(e) who is undergoing the first examination following surgery for colorectal cancer; or

(f) who is undergoing pre‑operative evaluation; or

(g) for whom a repeat colonoscopy is required due to inadequate bowel preparation for the patient’s previous colonoscopy; or

(h) for the management of inflammatory bowel disease;

other than a service associated with a service to which item 32230 applies

Applicable once on a day under a single episode of anaesthesia or other sedation

(Anaes.)

Fee: $380.90 Benefit: 75% = $285.70 85% = $323.80

(See para TN.8.2, TN.8.17, TN.8.152, TN.8.293 of explanatory notes to this Category)

Multiple Operation Rule

Endoscopic examination of the colon to the caecum by colonoscopy, for a patient:

(a) who has had a colonoscopy that revealed:

(i) one to 4 adenomas, each of which was less than 10 mm in diameter, had no villous features and had no high grade dysplasia; or

(ii) one or 2 sessile serrated lesions, each of which was less than 10 mm in diameter, and without dysplasia; or

(b) who has a moderate risk of colorectal cancer due to family history; or

(c) who has a history of colorectal cancer and has had an initial post‑operative colonoscopy that did not reveal any adenomas or colorectal cancer;

other than a service associated with a service to which item 32230 applies

Applicable once in any 5 year period

(Anaes.)

Fee: $380.90 Benefit: 75% = $285.70 85% = $323.80

(See para TN.8.2, TN.8.17, TN.8.152, TN.8.293 of explanatory notes to this Category)

Multiple Operation Rule

Endoscopic examination of the colon to the caecum by colonoscopy, for a patient who has a moderate risk of colorectal cancer due to:

(a) a history of adenomas, including an adenoma that:

(i) was 10 mm or greater in diameter; or

(ii) had villous features; or

(iii) had high grade dysplasia; or

(b) having had a previous colonoscopy that revealed:

(i) 5 to 9 adenomas, each of which was less than 10 mm in diameter, had no villous features and had no high grade dysplasia; or

(ii) one or 2 sessile serrated lesions, each of which was 10 mm or greater in diameter or had dysplasia; or

(iii) a hyperplastic polyp that was 10 mm or greater in diameter; or

(iv) 3 or more sessile serrated lesions, each of which was less than 10 mm in diameter and had no dysplasia; or

(v) one or 2 traditional serrated adenomas, of any size;

other than a service associated with a service to which item 32230 applies

Applicable once in any 3 year period

(Anaes.)

Fee: $380.90 Benefit: 75% = $285.70 85% = $323.80

(See para TN.8.2, TN.8.17, TN.8.152, TN.8.293 of explanatory notes to this Category)

Multiple Operation Rule

Endoscopic examination of the colon to the caecum by colonoscopy, for a patient who has a high risk of colorectal cancer due to having had a previous colonoscopy that:

(a) revealed 10 or more adenomas; or

(b) included a piecemeal, or possibly incomplete, excision of a large, sessile polyp;

other than a service associated with a service to which item 32230 applies

Applicable 4 times in any 12 month period

(Anaes.)

Fee: $380.90 Benefit: 75% = $285.70 85% = $323.80

(See para TN.8.2, TN.8.17, TN.8.152, TN.8.293 of explanatory notes to this Category)

Multiple Operation Rule

Endoscopic examination of the colon to the caecum by colonoscopy, for a patient who has a high risk of colorectal cancer due to:

(a) having either:

(i) a known or suspected familial condition, such as familial adenomatous polyposis, Lynch syndrome or serrated polyposis syndrome; or

(ii) a genetic mutation associated with hereditary colorectal cancer; or

(b) having had a previous colonoscopy that revealed:

(i) 5 or more sessile serrated lesions, each of which was less than 10 mm in diameter and had no dysplasia; or

(ii) 3 or more sessile serrated lesions, one or more of which was 10 mm or greater in diameter or had dysplasia; or

(iii) 3 or more traditional serrated adenomas, of any size;

other than a service associated with a service to which item 32230 applies

Applicable once in any 12 month period

(Anaes.)

Fee: $380.90 Benefit: 75% = $285.70 85% = $323.80

(See para TN.8.2, TN.8.17, TN.8.152, TN.8.293 of explanatory notes to this Category)

Multiple Operation Rule

Endoscopic examination of the colon to the caecum by colonoscopy, other than:

(a) a service to which item 32222, 32223, 32224, 32225 or 32226 applies; or

(b) a service associated with a service to which item 32230 applies

Applicable once

(Anaes.)

Fee: $380.90 Benefit: 75% = $285.70 85% = $323.80

(See para TN.8.2, TN.8.17, TN.8.152, TN.8.293 of explanatory notes to this Category)

Multiple Operation Rule

Removal of one or more polyps during colonoscopy, in association with a service to which item 32222, 32223, 32224, 32225, 32226, or 32228 applies

(Anaes.)

Fee: $307.25 Benefit: 75% = $230.45 85% = $261.20

(See para TN.8.2, TN.8.17, TN.8.152, TN.8.293 of explanatory notes to this Category)

Multiple Operation Rule

Endoscopic mucosal resection using electrocautery of a non‑invasive sessile or flat superficial colorectal neoplasm which is at least 25mm in diameter, if the service is supported by photographic evidence to confirm the size of the polyp in situ

Applicable once per polyp (H) 

(Anaes.)

Fee: $761.20 Benefit: 75% = $570.90

(See para TN.8.293 of explanatory notes to this Category)