Gastroenterology Coding Alert

Frequency rules vary for average, high risk patients.

If you're coding for colorectal cancer screening and worrying that your payer won't accept them, your protection could lie on following frequency guidelines and eligibility requirements exactly as instructed.

Could these 4 facts have the coding answers you're looking for? Read on!

1. Average Risk Patients Qualify for Colorectal Cancer Test

If the patient is at least 50 years old, he is eligible for a covered Medicare screening. These patients are considered average risk, and can have a colon cancer screening only once every 10 years, says Cheryl Ray, CCS, CPMA, of Atlantic Gastroenterology in Greenville, N.C.

Red flag: It's once in 10 years or nothing to most payers -- never more. Ignoring these frequency guidelines can spell trouble.

Example: A 68-year-old established Medicare patient reports for a screening colonoscopy on Dec. 5, 2009. The patient's records indicate that he last had a covered screening on Sept. 15, 1998. This makes the patient eligible for the screening. On the claim, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

2. Only One ICD-9 Links to G0121

As long as there is no need for any therapeutic intervention during the colonoscopy, payers require just one diagnosis code on all G0121 claims: V76.51 (Special screening for malignant neoplasms; colon). However, you can link secondary diagnoses, for instance diverticulosis (562.10) or hemorrhoids (455.0).

Remember: Always list the V code first for an average risk screening

3. Flex Sigmoidoscopy Limits Screening Eligibility

Depending on what other related colorectal cancer tests you performed on a patient previously, frequency rules differ. For instance, if a patient has had a routine flexible sigmoidoscopy screening (G0104, Colorectal cancer screening; flexible sigmoidoscopy), he is not entitled to a screening colonoscopy for at least 48 months.

Example: An average-risk established Medicare patient reports to the internist for a screening colonoscopy on Dec. 7, 2009. The patient's medical record indicates that he had a flexible sigmoidoscopy screening on Nov, 17, 2007. This patient is not now eligible under Medicare guidelines for a screening colonoscopy because it has been only three years since his sigmoidoscopy.

Another frequency rule allows high risk patients to a screening colonoscopy as often as once every 24 months, Ray notes. If the patient meets high risk criteria for coloerectal cancer, you would report G0105 (Colorectal cancer screening; colonoscopy on individual at high risk). You'll list a V code, such as V10.05 (History of colon cancer) or V12.72 (Diseases of digestive system; colonic polyps) as the primary diagnosis for these tests -- most of the time.

Tip: List a condition that puts the patient at high risk for colorectal cancer as primary diagnosis.

4. 45378 Works for Some Private Carriers

While many private payers accept the G code for colorectal cancer screening, some non-Medicare payers prefer 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 a screening colonoscopy. As a general rule, you should look for the private payer's frequency and diagnosis guidelines, which might differ from Medicare's, before coding these services.