Gastroenterology Coding Alert

Identify High-Risk Diagnoses for Screening Codes G0105 and G0120

Published on Sun Jun 01, 2003

If a patient presents with a personal history of malignant neoplasm of the large intestine, Medicare won't necessarily cover a high-risk colorectal screening the patient also has to meet age and frequency requirements.

If you want to be reimbursed for G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) and G0120 (Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema), you have to know which patients are considered at high risk for colorectal cancer.

The first step in identifying a high-risk patient is the patient-physician interview in which specific questions are asked regarding family or personal history of colorectal cancer and colon polyps, says DeAnne T. Owens, CPC, coding specialist with Waccamaw Gastroenterology in Georgetown, S.C.

Medicare outlines six characteristics that can classify an individual as high-risk: 1) having a close relative (sibling, parent, child) with colorectal cancer or adenomatous polyp, 2) a family history of familiar adenomatous polyposis, 3) family history of hereditary nonpolyposis colorectal cancer, 4) a personal history of adenomatous polyps, 5) a personal history of colorectal cancer, and 6) having inflammatory bowel disease (Crohn's disease, ulcerative colitis), says Beth Rudd, CPC, coding specialist with Tri-State Gastroenterology in Edgewood, Ky.

Translate High-Risk Characteristics Into Covered Diagnosis Codes

Medicare's high-risk criteria translate into the following diagnosis codes, according to a presentation at the annual AAPC meeting by Pat Stout, CPC:

V10.05 Personal history of malignant neoplasm of large intestine

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

V12.72 Personal history of colonic polyps

V16.0 Family history of malignant neoplasm, gastrointestinal tract

V18.5 Family history of colon polyps

555.0 Regional enteritis of small intestine

555.1 Regional enteritis of the large intestine

555.2 Regional enteritis of small intestine with large intestine

555.9 Regional enteritis of unspecified site

556.0 Ulcerative (chronic) enterocolitis

556.1 Ulcerative (chronic) ileocolitis

556.2 Ulcerative (chronic) proctitis

556.3 Ulcerative (chronic) proctosigmoiditis

556.8 Other ulcerative colitis

556.9 Ulcerative colitis, unspecified

558.2 Toxic gastroenteritis and colitis

558.9 Other and unspecified noninfectious gastroenteritis and colitis.

But you can't automatically report a high-risk screening code if a patient presents with one of the covered diagnoses you also have to consider age and frequency restrictions. "Age is a factor for most colorectal cancer screenings if the patient is covered by Medicare," Owens says, "and usually the age is 50."

Frequency limitations also need to be abided by before reporting G0105 and G0120. Owens reminds coders that frequency is something that has to be considered because most of the exams will be paid only if done in certain intervals. For example, a patient who is asymptomatic who had a covered, negative sigmoidoscopy three years ago will not qualify for a screening colonoscopy, she says: "The asymptomatic patient must wait at least another year before Medicare will cover the exam."

Rudd also points out that "a lot of times a patient doesn't mention if they've had a screening flexible sigmoidoscopy, for example, which is only covered every 48 months, so you really have to make sure they haven't had anything else done that you don't know about."

The chart in article 13 identifies the frequency and age restrictions and the physician requirements for reporting G0105, G0120 and the four other colorectal cancer screening codes issued by Medicare: G0104 (Colorectal cancer screening; flexible sigmoidoscopy), G0106 (Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema), G0107 (Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations) and G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).