All Non-Medicare Screening Colonoscopies Are Not Created Equal
Published on Thu Jan 27, 2005
Some private payers may prefer G codes for the test When a Medicare or private-pay patient reports to your office for a screening colonoscopy to check for colorectal cancer, you'll need to know how to report a colonoscopy that starts out as a screening but is diagnostic by the end of the encounter.
Knowing the basics of Medicare reporting for screenings is a must, and most gastroenterolgy coders are quite familiar with the coding choices.
The basics: Coders report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for an average-risk Medicare screening colonoscopy, while G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) is for high-risk Medicare patients, says Julia Covington, billing/collections office manager for Karen L. Woods, MD, in Houston. Coding Screenings Can Get Complex But screening colonoscopies aren't just for Medicare patients, so you'll also need to learn the rules for reporting the procedure to private payers - and it can get more complicated than you may think. (Did you know that some private payers would rather see Medicare G codes than CPT Codes on your claims for colorectal cancer screenings?)
Keep reading for pointers on when to use G codes to report screening colonoscopies, when to use CPT codes, and when the best option is to call and ask a carrier rep. Polyp Pushes Screening Colonoscopy to Diagnostic Before reading on, see how your coding expertise stacks up with a couple of experts. Try to answer the following real-life coding question, then read on for the experts' responses.
Test your knowledge: Let's say your gastro starts performing a screening colonoscopy for an average-risk Medicare patient. She then sees a polyp, which she biopsies.
In this scenario, what should you report?:
45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple)
G0121
G0121 and 45380 with modifier -59 (Distinct procedural service) attached
Some other code(s). Experts Agree: Leave G Code off of This Claim We put this very question to a pair of seasoned coders, and here's what they had to say.
Expert 1: "I would report code 45380," Covington says.
Explanation: "Once the polyp is visualized and biopsy performed, the diagnosis would have to change from V76.51 (Special screening for malignant neoplasms; colon) to 211.3 (Benign neoplasm of other parts of digestive system; colon)," she says.
Expert 2: "If during the course of the screening colonoscopy, a lesion or growth is detected that results in a biopsy or removal of the growth, the appropriate diagnostic procedure [45380] should be billed and paid rather than code G0121," says Margie Pfaff, CPC, corporate compliance analyst for Wisconsin's Medical Associates Health Centers.
Best advice: Follow the experts' lead and report CPT 45380 when a gastro biopsies a [...]
