Gastroenterology Coding Alert

High risk patients younger than 50 require your special attentionYou'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.Apply These Average Risk TipsAnswer 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.Confront the Age for High Risk Patients Head OnAnswer 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 [...]