Gastroenterology Coding Alert

As Medicares colorectal screening benefits become more widely publicized, primary care physicians (PCPs) are referring an increasing number of patients to gastroenterologists for high-risk screening colonoscopies. If the patient has a chronic gastrointestinal disease, however, the gastroenterologist may be able to report a diagnostic colonoscopy instead of a high-risk screening and bill an evaluation and management (E/M) service along with the encounter. Some local carriers are beginning to require that a follow-up colonoscopy performed on a patient who has a personal history of polyps and no additional gastrointestinal symptoms be reported as a high-risk screening procedure instead of a diagnostic one.

Screening Colonoscopies for Those at Risk

Medicares national policy on colorectal screening, which was passed as part of the Balanced Budget Act of 1998, stipulates that screening colonoscopies are covered once every 24 months for beneficiaries at high risk for colorectal cancer. Unlike the other colorectal screening benefits, there is no minimum age requirement.

Medicares national policy defines high risk for colorectal cancer as an individual with one or more of the following:

Close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyposis;

Family history of familial adenomatous polyposis;

Family history of hereditary nonpolyposis colorectal cancer;

Personal history of colorectal cancer; or

Inflammatory bowel disease, including Crohns disease and ulcerative colitis.

The designation of specific ICD-9 codes that should be used to establish the beneficiarys high-risk status has been left to the individual carriers and varies significantly from state to state. (For more on these codes, see Choosing Correct ICD-9 Codes for Colorectal Cancer Screenings on page 5 of the January 2000 Gastroenterology Coding Alert.)

Medicare Requires G0105 for High-risk Screening

Medicare requires HCPCS code G0105 (colorectal cancer screening; colonoscopy on individual at high risk) when reporting screening colonoscopies performed on asymptomatic patients at high risk. Use 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]) to report diagnostic colonoscopies performed on patients exhibiting signs and symptoms of gastrointestinal disease.

If, during the course of a high-risk screening colonoscopy, the gastroenterologist finds a polyp, lesion or other growth, the appropriate diagnostic colonoscopy procedure code (45378-45385) should be billed instead of G0105.

Determine Whether Patients Qualify

Although Medicares national policy seems quite detailed, physicians are still unclear about what is covered. The high-risk screening benefit is one of the hardest policies to interpret, says Christine Martin, CPC, practice manager at Commonwealth Gastroenterology Associates, a three-physician practice in Lexington, Ky.

Because this Medicare policy is relatively new, many primary care physicians often are confused about what it covers, says Martin, who adds that most of [...]