Gastroenterology Coding Alert

Billing colorectal cancer screenings for asymptomatic patients can be confusing for many gastroenterologists because each state Medicare carrier seems to have its own rules concerning how to bill for these procedures. Although Medicare coverage of various colorectal cancer screening examinations was enacted with the passage of the Balanced Budget Act of 1997, gastroenterologists need to be precise in their use of ICD 9 diagnostic and HCPCS codes when they bill for these procedures to maximize reimbursement.

Medicares coverage of colorectal screening tests for asymptomatic patients includes the following procedures furnished to an individual for the early detection of cancer:

- Screening fecal-occult blood tests are covered at a frequency of once every 12 months for beneficiaries who have attained age 50.
- Screening flexible sigmoidoscopies are covered at a frequency of once every 48 months for beneficiaries who have attained age 50.
- Screening colonoscopies are covered at a frequency of once every 24 months for beneficiaries at high risk for colorectal cancer.
- Screening barium enema examinations are covered as an alternative to either a screening sigmoidoscopy or screening colonoscopy examination. The same frequency parameters specified in the screening sigmoidoscopies or colonoscopies apply.

A patient must fall into the high-risk category for colorectal cancer to qualify for a screening colonoscopy or screening barium enema. For a patient to be classified as high risk, you have to use a certain diagnosis, says Peg Hopwood, supervisor of patient accounts for Rockford Gastroenterology, a practice of nine gastroenterologists in Rockford, Ill. You dont get paid just because the patient has colorectal cancer screening as a benefit.

HCFAs Two Definitions of High Risk

The Health Care Financing Administration (HCFA) states that high risk for colorectal cancer means an individual with one or more of the following:

-a close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyposis;
- a family history of familial adenomatous polyposis;
- a family history of hereditary nonpolyposis
colorectal cancer;
- a personal history of adenomatous polyps;
- a personal history of colorectal cancer; or
- inflammatory bowel disease, including Crohns
disease and ulcerative colitis.

To be reimbursed for the screening, gastroenterologists must include an accepted diagnosis code denoting the high-risk status of the patient with the procedure code. HCFA states that the following ICD 9 Codes are examples of diagnoses that meet the high-risk criteria for colorectal cancer:

- V10.05personal history of malignant neoplasm of
large intestine
- V10.06personal history of malignant neoplasm of
rectum, rectosigmoid junction, and anus
- 555.0regional enteritis of small intestine
- 555.1regional enteritis of large intestine
- 555.2regional enteritis of small intestine with large intestine
- 555.9regional enteritis of unspecified site
- 556.0ulcerative (chronic) enterocolitis
- 556.1ulcerative (chronic) ileocolitis
- 556.2ulcerative (chronic) proctitis
- 556.3ulcerative (chronic) proctosigmoiditis
- 556.8other ulcerative colitis
- 556.9ulcerative colitis, unspecified
- 558.2toxic gastroenteritis and colitis
- 558.9other and unspecified noninfectious gastroenteritis and colitis

HCFA seems to have set an inconsistent standard because it includes characteristics such as a family history with colorectal cancer (V16.0, V19.8) in its definition of what constitutes high-risk factors but leaves those diagnoses off its list of approved ICD-9 codes.

The final determination of what is an appropriate diagnosis for being at high risk has been left with the state Medicare payers, however, and the codes that each one will accept can vary significantly.

Working With Different Local Medicare Payers

In California, for example, the Medicare carrier has an approved list of diagnosis codes that exactly matches HCFAs. The list of codes approved for Wisconsin, on the other hand, includes all of HCFAs, plus several more.

Because the list of approved codes changes from state to state, Hopwood recommends that gastroenterologists contact their local Medicare payers and get the approved list directly from them.

You really need to check with your local carrier on the most up-to-date list of approved codes, she emphasizes. I call the provider hotline and ask them to tell me what Medicare bulletin contains the list or have them send it directly to me.

Although screening fecal-occult blood tests and screening flexible sigmoidoscopies do not carry the high-risk stipulation, when billing for these services gastroenterologists also must include a proper diagnosis code, adds Hopwood. Again, she recommends that gastroenterologists check directly with their state medical director to get a copy of the list of approved codes for screening fecal-occult blood tests and flexible sigmoidoscopies.

Use the Proper HCPCS Code

In addition to using the correct diagnosis code, gastroenterologists should bill their Medicare claims for asymptomatic patients with the proper HCPCS code for the specific screening service provided.

HCFA states that the following HCPCS codes should be used with Medicare claims for colorectal cancer screening services:

- Screening fecal-occult blood tests use G0107;
- Screening flexible sigmoidoscopies use G0104;
- Screening colonoscopies for individuals at high risk use G0105;
- Screening barium enemas as an alternative to a screening sigmoidoscopy (G0104) use G0106
- Screening barium enemas as an alternative to a screening colonoscopy (G0105) use G0120.

The following HCPCS codes should be used when billing a colorectal cancer screening test for an individual who does not meet the criteria for being at high risk:

- Colorectal cancer screening; colonoscopy (G0121)
- Colorectal cancer screening; barium enema (G0122)

Gastroenterologists using either code G0121 or code G0122 will not be reimbursed by Medicare, explains Hopwood, and should use those codes only when the patient is expected to pay for the service.

Screening vs. Diagnostic Services

Gastroenterologists should not confuse codes used to report colorectal screening services with the CPT codes used to report diagnostic services. The HCPCS codes are used when the patient is asymptomatic, regardless of whether he or she is at high risk for colorectal cancer, explains Hopwood. If the patient comes in with a symptom such as blood in stool and the gastroenterologist performs a colonoscopy, then code 45378 (colonoscopy) should be used to bill for the diagnostic service.

Likewise, fecal-occult blood tests for diagnostic evaluation of symptomatic patients should be billed using the CPT code 82270 (blood, occult; feces, 1-3 simultaneous determinations).

Gastroenterologists also should ensure that patients referred to them for colorectal screenings are actually asymptomatic. Many times patients are referred for a screening when they really have symptoms, and those pro-cedures should be coded as diagnostic, Hopwood says.