Colorectal Cancer Screening: A Medicare Coding & Billing FAQ

Steer clear of G0121 denials with these tips.

If you slip up on screening colonoscopy claims’ frequency guidelines and eligibility requirements, Medicare will pay you zilch. But our colorectal cancer screening FAQ provides you the coding the know-how you need to soar through your coding duties with the greatest of ease.

Q: Who’s Eligible for Average-Risk Test?

Any Medicare patient 50 years or older is eligible for a covered Medicare screening, confirms Dena Rumisek, CPC, biller at Michigan’s Grand River Gastroenterology PC.

Catch: These patients can have a colorectal cancer screening only once every 10 years, says Cheryl Ray, CCS, CPMA, of Atlantic Gastroenterology in Greenville, N.C. You’d be wise to pay attention to the frequency guidelines, as “Medicare is very stringent on the date … it has to be 10 years or longer — it can’t be 9 years and 360 days” between covered screening colonoscopies, assures Rumisek.

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Example: A 73-year-old established Medicare patient reports for a screening colonoscopy on Aug. 11, 2009. The patient’s records indicate that he last had a covered screening on July 31, 1995. On the claim, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

One bit of simplicity: Report G0121 if there is no need for any therapeutic intervention during the colonoscopy. All G0121 claims require only one diagnosis code: V76.51 (Special screening for malignant neoplasms; colon). You might list other identified conditions secondarily, including diverticulosis (562.10) or hemorrhoids (455.0).

Always list the V code first, however.

Q: What If the Patient Had a Recent Sigmoidoscopy?

The frequency rules differ depending on whether other related colorectal cancer tests were performed previously; if a patient has had a routine flexible sigmoidoscopy screening (G0104, Colorectal cancer screening; flexible sigmoidoscopy), he is not entitled to a screening colonoscopy for at least 48 months, advises Cynthia Swanson RN, CPC, senior managing consultant for Seim, Johnson, Sestak & Quist LLP in Omaha, Neb.

Example: An average-risk established Medicare patient reports to the gastroenterologist for a screening colonoscopy on Sept. 18, 2009. The patient’s medical record indicates that he had a flexible sigmoidoscopy screening on April 7, 2007.

This patient is not now eligible under Medicare guidelines for a screening colonoscopy because it has been only three years since his sigmoidoscopy.

Q: What Are the Rules for High-Risk Patients?

A patient who is considered at high risk for colorectal cancer is entitled to a screening colonoscopy once every 24 months, Ray says. You’ll list a V code (such as V10.05, Personal history of malignant neoplasm; large intestine; or V12.72, Personal history of certain other diseases; diseases of digestive system; colonic polyps) as the primary diagnosis for these tests — most of the time.

Exception: If a patient has a condition that automatically puts him at high risk for colorectal cancer, then you would list that condition as the primary diagnosis (for instance, Crohn’s disease or ulcerative colitis; check your spell local coverage determination [LCD] for your payer’s specific list).

Example: A 69-year-old established Medicare patient with a personal history of colonic polyps reports to the gastroenterologist for a colonoscopy screening on Sept. 1, 2009. The patient record indicates that the patient’s last colonoscopy screening was May 4, 2006. On the claim, report G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) with V12.72 appended.

Q: Can I Bill Private Payers for Screenings?

It depends. Some private payers will reimburse for colonoscopy screenings —their coding practices for these services, however, can differ from Medicare. Many U.S. states have passed legislation similar to the Medicare regulations requiring all health insurance carriers to cover routine colorectal cancer screening starting at age 50.

Most non-Medicare payers accept 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing; with or without colon decompression [separate procedure]) for a screening colonoscopy, Ray relays. Before coding these services, check the payer’s frequency and diagnosis guidelines. “Each carrier pays [for screenings] according to the patient’s policy,” she says.

G codes possible: Other private payers might want you to code the same way as Medicare. For instance, BCBS of Michigan accepts the G codes and follows most of the same diagnosis guidelines as Medicare, says Rumisek.

Best bet: Check with your private payers before coding any screening colonoscopy services.

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