# Medicare not covering colonoscopy for fam. hx of colon cancer



## Hayley_Sutton (Feb 25, 2016)

I am getting a ton of denials from Medicare for colonoscopies performed with the indication Z80.0-Family history of colon cancer. The remark code is: 49- These are non covered services because this is a routine exam or screening procedure done in conjunction with a routine exam. It denies patients that we have not billed an office exam with any routine indications. I called Medicare and the rep just kept saying it was not on their list to support medical necessity. I haven't had this issue until recently. They deny any claim with the code; polyp removal or no polyp removal. 

Anyone else having this issue or know the fix?


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## thomas7331 (Feb 27, 2016)

I'm not sure what HCPCS or CPT codes you're billing in this situation or who your Medicare payer is, but our MAC only accepts the Z80.0 for medical necessity for the high risk colonoscopy code G0105.  For the non-high risk code G0121, the only diagnosis codes that support medical necessity are the screening codes Z12.11 or Z12.12.  Best to check your MAC's local coverage determination to get the most current information on this.


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## ValerieBatesHoffCPCCPMA (Mar 15, 2016)

*Patients with a family history of colon cancer without a personal history of symptoms*

*Local Coverage Determination (LCD): Diagnostic Colonoscopy (L34213)*


*Coverage Indications, Limitations, and/or Medical Necessity*

Colonoscopy is a visual examination of the lining of the large intestine using a rigid or flexible video or fiberoptic endoscope. The procedure includes inspection of the entire colon, from the rectum to the cecum, and may include the examination of the terminal ileum. A colonoscopy, by definition, must examine the colon proximal to the splenic flexure. The colonoscope is inserted via the anus or stoma, and then advanced under direct vision or video image. A rigid sigmoidoscope may be used for an intraoperative transcolotomy approach.

A colonoscopy requires the use of an instrument that has the potential to examine the entire colon, and must potentially reach the entire colon (i.e. the cecum).

Do not report a colonoscopy procedure code for an endoscopy performed with a sigmoidoscope on a patient with a normal length colon, even if the sigmoidoscope reaches proximal to the splenic flexure. A sigmoidoscope (an endoscope typically 65 centimeters in length) may be used for a colonoscopy only if the bowel is sufficiently short so that the entire colon may be examined. 

A *diagnostic* colonoscopy is *indicated *for the following:


Evaluation of an abnormality discovered by a barium enema that is likely to be clinically significant, such as a filling defect or a stricture,

Evaluation of unexplained gastrointestinal bleeding:


Hematochezia that is not from the rectum or a perianal source,

Melena of unknown origin, or

Presence of fecal occult blood


Unexplained iron deficiency anemia,

Surveillance of colonic neoplasia:


Evaluation of the entire colon for a synchronous cancer or polyps in a patient with treatable cancer or polyps,

Surveillance of selected patients with Crohn’s colitis, or chronic ulcerative colitis. Suitable candidates are those with:


Pancolitis of greater than seven years duration, or

Left-sided colitis of over 15 years duration,

Chronic inflammatory bowel disease of the colon when a more precise determination of the extent of disease will influence management,

Clinically significant diarrhea of unexplained origin,

Intraoperative identification of the site of a lesion that cannot be detected by palpation or gross inspection at surgery,

Evaluation of acute colonic ischemia/ischemic bowel disease,

Evaluation of patients with streptococcus bovis endocarditis,

Treatment of bleeding from such lesions as vascular anomalies, ulceration, and neoplasia,

Removal of foreign body,

Excision of colonic polyps,

Decompression of pseudo-obstruction of the colon (Ogilvies’ Syndrome),

Treatment of sigmoid volvulus,

Suspected disease of terminal ileum, or

Chronic abdominal pain unresponsive to medical therapy.

*Diagnostic* colonoscopy is *not* covered for evaluation of the following:

Chronic, stable irritable bowel syndrome,

Acute limited diarrhea,

Hemorrhoids,

Metastatic adenocarcinoma of unknown primary site in the absence of colonic symptoms, and when a definitive site of origin will not influence management,

Routine follow-up of inflammatory bowel disease (except as indicated above in this section),

Routine examination of the colon in patients about to undergo elective abdominal surgery for noncolonic disease,

Upper GI bleeding or melena with a demonstrated upper GI source,

Bright red rectal bleeding in patients with a convincing anorectal source via direct examination, anoscopy, or sigmoidoscopy and no other symptoms suggestive of a more proximal bleeding source,

*Patients with a family history of colon cancer without a personal history of symptoms.*

https://www.cms.gov/medicare-covera...ctr=365&s=67&DocType=All&bc=AggAAAIAAAAAAA==&


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## ValerieBatesHoffCPCCPMA (Mar 15, 2016)

*Medicare Preventive Services -  Colorectal Cancer Screening - Page 4*

*Colorectal Cancer Screening *

*HCPCS/CPT Codes*
G0104 – Flexible Sigmoidoscopy
G0105 – Colonoscopy (high risk)
G0106 – Barium Enema (alternative to G0104)
G0120 – Barium Enema (alternative to G0105)
G0121 – Colonoscopy (not high risk)
G0328 – Fecal Occult Blood Test (FOBT), immunoassay, 1-3 simultaneous
G0464 – Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3)

*ICD-10-CM Codes*
See https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html for individual ChangeRequests (CRs) and coding translations for ICD-10

*Who Is Covered*
For colorectal cancer screening using Cologuard™—a Multitarget Stool DNA (sDNA) Test: All Medicare beneficiaries:

• Aged 50 to 85 years;
• Asymptomatic; and
• At average risk of developing colorectal cancer 

For screening colonoscopies, FOBTs, flexible sigmoidoscopies, and barium enemas: All Medicare beneficiaries:

• Aged 50 and older who are at normal risk of developing colorectal cancer; or
• At high risk of developing colorectal cancer 

“High risk for developing colorectal cancer” is defined in the Code of Federal Regulations (CFR) at 42 CFR 410.37(a)(3).

NOTE: For coverage of screening colonoscopies, there is no age limitation.

https://www.cms.gov/Medicare/Preven...wnloads/MPS-QuickReferenceChart-1TextOnly.pdf


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## orazzals (May 27, 2016)

*I agree*



thomas7331 said:


> I'm not sure what HCPCS or CPT codes you're billing in this situation or who your Medicare payer is, but our MAC only accepts the Z80.0 for medical necessity for the high risk colonoscopy code G0105.  For the non-high risk code G0121, the only diagnosis codes that support medical necessity are the screening codes Z12.11 or Z12.12.  Best to check your MAC's local coverage determination to get the most current information on this.



I agree with this. With a family history of you need to bill G0105 - High risk screening with the Z80.0. If there were findings and a biopsy was taken you would bill 45380 with a PT modifier, the Z80.0 and whatever your findings were.


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