Gastroenterology Coding Alert

Find out what age is the magic number for average-risk patients

You have to know all the basics of Medicare's screening policy for patients who present to your gastroenterologist for a colorectal cancer screening colonoscopy--or you could face a denial.

Our experts highlight age and frequency requirements for an average-risk Medicare-approved screening, but watch out: the guidelines only get more stringent when you-re coding for a high-risk screening.

Remember: If your gastroenterologist provides a colorectal cancer screening to a Medicare patient who does not meet screening parameters, the practice will have to cover the screening. Attack Requirements for Average-Risk Patients Medicare allows patients who are at average risk of colorectal cancer to receive covered screening colonoscopies once every 10 years, says Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia. These patients must also be at least 50 years old, she says.

Example: A 60-year-old average-risk patient reports for a colonoscopy screening to check for colorectal cancer on March 2, 2007. The gastroenterologist provides the screening and sends the patient home. On the claim, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for the screening.

Unless this patient's risk category changes, he is not entitled to another covered screening until March 2, 2017.

Caveat: 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, Swanson says. So if a 54-year-old average-risk Medicare patient had a flexible sigmoidoscopy screening on May 5, 2004, he would not be eligible for a covered colonoscopy screening until at least May 5, 2008. Learn What You Need for G0121 Many Medicare carriers require only that the patient be older than 50 years of age to receive G0121 service, Pohlig says. But some payers may have certain medical-necessity requirements specific to their regions.

Best bet: If you don't know the payer's policy on G0121, check its local coverage determination for more information, Swanson says. -LCDs will contain diagnosis information specific to medical necessity for G0121,- she says. Provide ICD-9 Proof for High-Risk Screenings When your gastroenterologist performs a colonoscopy screening on a Medicare patient at high risk for colorectal cancer, you-ll code the encounter with G0105 (Colorectal cancer screening; colonoscopy on individual at high risk). Medicare entitles patients at high risk to a covered screening once every two years, Pohlig says.

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