Gastroenterology Coding Alert

Question: How should I code a colonoscopy for a Medicare patient who has symptoms that are not listed on the policy's covered diagnosis list? For example, consider a patient who has rectal bleeding, abdominal pain with unknown etiology, constipation, etc.

Iowa Subscriber

Answer: Carriers vary on payable diagnoses. You can find your local medical policy on lmrp.net or contact the insurer.

When the patient's symptom is not covered for a diagnostic colonoscopy (45378-45387), you should report a screening colonoscopy (G0105, Colorectal cancer screening; colonoscopy on individual at high risk; or G0121, Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

If the patient exhibits acceptable signs or symptoms, such as rectal bleeding (569.3), list those diagnoses. Absent any signs or symptoms, report V76.51 (Special screening for malignant neoplasms; intestine; colon).

If the colonoscopy reveals any findings, change the CPT code and diagnosis code to match them. For example, suppose a Texas Medicare patient who has rectal bleeding presents to a gastroenterologist for a colonoscopy. Trailblazer of Texas does not cover 569.3 for a colonoscopy. Report a screening colonoscopy (G0105, G0121).

However, if the gastroenterologist removes a polyp, report the diagnostic colonoscopy (45384-45385) and the clinical results (e.g., 211.3, Benign neoplasm of colon). The carrier covers this finding.

You should obtain an advance beneficiary notice to allow your practice to collect payment from the patient if the carrier denies medical necessity for the screening colonoscopy.