Gastroenterology Coding Alert

Example: Suppose a Medicare patient with a history of regional enteritis reports for a high-risk screening. On the claim, you must reflect the patient's high-risk characteristics by attaching 555.9 (Regional enteritis; unspecified site) to G0105 to represent the patient's enteritis.
 
(For a more comprehensive list of ICD-9 codes that signify high-risk characteristics in Medicare patients, see "You Be the Coder: Dx Codes and High-Risk Patients" on page 43.)

V Codes Are Often Necessary

Many G0105 claims will include a V code, though there are a couple of exceptions. If a patient has a chronic digestive disease that your Medicare carrier covers, then a V code may not be necessary - though you should still include an appropriate ICD-9 code, Parks says.
 
Check with your local Medicare payer for a list of chronic diseases that do not require a V code for a G0105 encounter. 

Patient Must Be Old Enough for G0105

Even if a patient has the characteristics of an individual at high risk for colorectal cancer, most Medicare carriers will not cover a G0105 screening unless the patient is at least 50 years old, Parks says.
 
However, there may be some local Medicare carriers that don't have age requirements written into their policies. For example, "Part B-Texas Trailblazer Health does not indicate an age requirement for a Medicare recipient to meet the high-risk criteria," says Julia Covington, who works in the offices of Karen Woods, MD, in Houston.
 
Best bet: Most Medicare carriers are going to deny G0105 claims for patients under 50, so before even considering filing G0105 for a patient under 50, make sure to research your contract with the carrier. Then, call and speak to a representative to make sure it's an acceptable practice.

Get Time on Your Side

If your Medicare patient is of acceptable age and exhibits characteristics of an individual at high risk for colorectal cancer, you only have to meet frequency requirements before the G0105 claim is kosher.
 
Two-year rule in effect: Medicare will cover a G0105 screening for a beneficiary once every 24 months,  Covington says. Attempts to report G0105 for the same patient more than once in a two-year span will result in denials.

Rule in practice: "If the gastroenterologist performed a high-risk screening in January 2005, the Medicare beneficiary is not eligible to receive another high-risk screening until January 2007 and in most cases does not get another screening until 2010," Parks says.
 
Remember that even though Medicare covers a screening every two years, most high-risk patients don't require screenings more often than every three to five years.