Gastroenterology Coding Alert

If you don't know the risk category for patients who receive screening colonoscopies, your bottom line will suffer

With the rising popularity of screening colonoscopies to detect colorectal cancer, it's more vital than ever before to know the risk level for each patient receiving the service. Avoid picking up the tab on scads of Medicare bills for screening colonoscopies with these tips on differentiating your high-risk patients from those Medicare puts in the average-risk category.

In July 2001, Medicare began paying for average-risk screening colonoscopies at a frequency of once every 10 years for patients 50 and older. For example, if an average-risk patient had a screening colonoscopy in August 2003, Medicare would not cover another one until August 2013.

"An average-risk patient is entitled to a screening colonoscopy every 10 years, and we report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) to Medicare for this service," says Debbie Broom, RN, at the offices of Dr. Mark Appler in Mount Airy, N.C.

Enforce the Criteria

If a patient is identified at high risk for colorectal cancer, however, he is still entitled to a screening colonoscopy once every two years, which you should code G0105 (Colorectal cancer screening; colonoscopy on individual at high risk).

Both Broom and Kimberly Ingoldsby, billing supervisor at Albany (N.Y.) Gastroenterology Associates, have seen a surge in patients requesting average-risk screening colonoscopies since the 2001 Medicare legislation. Ingoldsby knows that enforcing the  high-risk criteria is essential if you want maximum reimbursement for your office. Otherwise, there's potential for trouble when the bill arrives.

 "If they don't have a family history or any other high-risk criteria, they're average-risk," Ingoldsby says simply, meaning they will only receive a Medicare-covered screening colonoscopy once every decade.

So What's High Risk?

The trouble with identifying high risk is that Medicare has no uniform definition of it. There are some widely accepted indicators of high risk of colorectal cancer in a patient, Ingoldsby says, but there are also indicators that are not accepted by all Medicare carriers as high-risk diagnoses.

"Family history of colorectal cancer is the big one, and also family history of adenomatous polyposis" is an  obvious high-risk indicator, as well as people with inflammatory bowel disease, Crohn's disease or ulcerative colitis, she says.

Codes for Medicare Carriers

Some of the ICD-9 codes that Medicare carriers consider indicators of diagnoses of high risk in a patient - and therefore justify G0105 screenings - include V10.05 (Personal history of malignant neoplasm; gastrointestinal tract; large intestine), V12.72 (Personal history of certain other diseases; diseases of digestive system; colonic polyps), V16.0 (Family history of malignant neoplasm; gastrointestinal tract), V18.5 (Family history of certain other specific conditions; digestive disorders; colon polyps) and 555.0 (Regional enteritis of small intestine).

Beware: Because Medicare has no national determination for G0105, you should contact your Medicare local medical review policy (LMRP) to get its most recent list of approved diagnosis codes that identify patients at high risk of colorectal cancer. Get Medicare to send you the list, photocopy it and hand it out to all of your colleagues, including your physicians.

Adjust for Screenings-Turned-Diagnostic

Medicare has not clearly defined when a colonoscopy stops being a screening and starts being diagnostic, but Medicare seems to apply the rule of common sense, Ingoldsby says.

"You should not bill Medicare for two separate colonoscopies" when polyps are biopsied or removed during what started off as a screening colonoscopy, she warns coders.

Broom agrees: "If the doctor goes in to do the average-risk screening and removes a polyp, then you can't report G0121. Report the diagnostic colonoscopy code for polyp removal."

Colonoscopy Example

For example, let's say a gastroenterologist finds two polyps while performing a screening colonoscopy and removes them using snare technique during the procedure. You would report 45385 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesions[s] by snare technique). You should also report an ICD-9 code to represent where the polyps were found, such as 211.3 for colonic polyps.

While polyp removal automatically makes a colonoscopy diagnostic, identifying other findings or abnormalities, like hemorrhoids, does not necessarily mean Medicare considers it diagnostic.

If your doctor finds hemorrhoids during a screening, you're better off sticking with G0121 or G0105 rather than trying to code for a diagnostic procedure. Hemorrhoids are not a covered diagnosis for any of the codes in the colonoscopy family (45378-45387), so diagnostic reimbursement is unlikely.

If you are unsure whether an average-risk or high-risk screening colonoscopy will be covered by Medicare for any reason, get an advance beneficiary notice (ABN) from the patient before proceeding. (For more information on advance beneficiary notices, see "Use ABNs if You Think Medicare Might Not Pay").