Gastroenterology Coding Alert

You've taken the colonoscopy coding challenge on page 75 -- and now it's time to see how you fared. Compare your answers to our experts' responses.

Answer 1: On the claim, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for the screening. Your diagnosis code is V76.51 (Special screening for malignant neoplasms; colon), says Paula Duty, assistant office manager and A/R manager at Medical Specialists of Cookeville, PLLC in Tenn. Medicare will cover this because this patient is at least 50 years old.

Unless this patient's risk category changes, he is not entitled to another covered screening until March 2, 2018. According to accepted evidence-based guidelines, the patient should undergo another screening in ten years -- but individual carriers may allow screening at different intervals.

Note: For non-Medicare patients, you would report 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 the colonoscopy and V76.51 for your diagnosis, Duty adds.

Answer 2: If your patient has had a Medicare-covered cancer screening via flexible sigmoidoscopy (G0104, Colorectal cancer screening; flexible sigmoidoscopy) within the last 48 months, he is not eligible for a colonoscopy screening, says Cynthia Swanson, RN, CPC, senior managing consultant for Seim, Johnson, Sestak & Quist LLP, in Omaha, Neb.

According to Medicare, average risk patients who have had covered flexible sigmoidoscopy screenings must wait four years before having a covered colonoscopy screening. So if a 54-year-old, average-risk Medicare patient had a flexible sigmoidoscopy screening on Sept. 5, 2006, he would not be eligible for a covered colonoscopy screening until at least Sept. 5, 2010.

Answer 3: Some payers might set a minimum age of 50 for covered high risk screenings, even though Medicare has no age requirement for G0105 (Colorectal cancer screening; colonoscopy on individual at high risk). "For beneficiaries considered to be at high risk for developing colorectal cancer, Medicare covers one screening colonoscopy every two years, regardless of age," according to MLN Matters article SE0613.

Keep in mind: Evidence-based guidelines recommend an interval of every two years for individuals with familial polyposis syndromes, those with hereditary colon cancer syndrome (HNPCC), and those with longstanding inflammatory bowel disease. Guidelines also advise patients considered to be "high risk" (because of a prior history of colon cancer, history of colon polyps, or because of a family history of colon cancer or polyps) to have follow-up surveillance at three- to five-year intervals.

Tip: Despite this edict from Medicare, you might still have trouble getting G0105 claims paid for patients younger than 50 years of age. If you get a denial for G0105 because the patient is under 50, contact the payer and reference MLN Matters article SE0613.

Answer 4: The most important aspect of a successful G0105 claim is proving medical necessity for the service. You can prove necessity through the patient's personal and family history, and exact ICD-9 coding. Therefore, you would report G0105 for the screening, as well as V16.0 (Family history of malignant neoplasm; gastrointestinal tract) and V18.59 linked to G0105 to prove medical necessity for the screening.

An individual at high risk for colorectal cancer could have one or more of the following characteristics:

• A close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp

• A family history of familial adenomatous polyposis

• A family history of hereditary nonpolyposis colorectal cancer

• A personal history of colorectal cancer

• A personal history of adenomatous polyps

• Inflammatory bowel disease, including Crohn's disease, and ulcerative colitis.

For diagnosis codes that meet the high risk criteria, you may have these choices:

• 555.0, 555.1, 555.2, 555.9 -- Regional enteritis ...

• 556.0, 556.1, 556.2, 556.3 -- Ulcerative colitis ...

• 556.8 -- Other ulcerative colitis

• 558.2 -- Toxic gastroenteritis and colitis

• 558.9 -- Other and unspecified noninfectious gastro-enteritis and colitis

• V10.05 -- Personal history of malignant neoplasm; large intestine

• V10.06 -- Personal history of malignant neoplasm; rectum, rectosigmoid junction, and anus

• V12.72 -- Personal history of diseases of digestive system; colonic polyps

• V16.0 -- Family history of malignant neoplasm; gastrointestinal tract

• V18.51 -- Family history of colonic polyps

• V18.59 -- Family history of other digestive disorders.

Note: This is not an all-inclusive list of acceptable diagnosis codes for G0105.

Bonus Answer 5: If the physician discovers a polyp during the screening, you should report a diagnostic colonoscopy (45380, Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple), Duty says.

When your gastroenterologist starts out performing a screening colonoscopy for colorectal cancer but ends up addressing another problem during the colonoscopy, you should report the appropriate procedure code and leave G0105 off the claim, Swanson says.

And when the gastroenterologist visualizes and biopsies the polyp, you'll find some controversy about which diagnosis codes to use and in which order to report them. Some Medicare carriers still want you to report V76.51 as the primary diagnosis and then code the polyp result, for instance, 211.3 (Benign neoplasm of other parts of digestive system; colon). Other carriers require you switch the these diagnosis codes' order.

Another consideration: If the gastroenterologist finds an adenomatous or other high risk histologic polyp during a screening, the patient is automatically at high risk for colon disease and therefore qualifies for more frequent screenings. Also, if the physician feels the need to give the patient another colonoscopy, it will automatically be diagnostic, like a mammogram after a breast tumor.

A final note: If the physician finds a less serious problem, such as diverticulosis (562.10, Diverticulosis of colon [without mention of hemorrhage]) or hemorrhoids (455.X), the colonoscopy would remain a screening. If such findings cause a change in family history, however the patient might qualify as "high risk" and receive covered screening colonoscopies more often.