Gastroenterology Coding Alert

Question: How do we get reimbursed by Medicare for performing colorectal screening procedures on patients at average risk and done in accordance with guidelines set up by the American Society of Gastrointestinal Endoscopy (ASGE)?

Tammy Nester
Consolidated Medical Specialties, Columbus, OH

Answer: Medicare does not have to reimburse for a procedure just because it is part of a guideline set by a medical society. In the case of colorectal screening for patients of average risk, Medicares national reimbursement policy is pretty much in line with what the ASGE recommends.

The Balanced Budget Act of 1997 provides for coverage of various colorectal screening examinations for patients over the age of 50. The provisions for patients at average risk, meaning they are asymptomatic and have no other risk factors, are listed below. The ASGE recommendations are then given in parentheses.

Screening fecal-occult blood tests (HCPCS code G0107) are covered at a frequency of once every 12 months. (ASGE: Offer fecal occult blood screening each year.)

Screening flexible sigmoidoscopies (G0104) are covered at a frequency of once every 48 months. (ASGE: Offer screening sigmoidoscopy with a flexible sigmoidscope every five years.)

Screening barium enema examinations (G0106) are covered as an alternative to a screening sigmoidoscopy. The same frequency parameters apply. (ASGE: Offer double-contrast barium enema every six to 10 years.)

If you are having trouble getting reimbursement for the fecal-occult blood tests (FOBT), also known as guaiac test, it could be because you arent using the correct code. The HCPCS code G0107 should be used when screening for colorectal cancer. If an FOBT is performed for anything other than colorectal cancer screening, then the code 82270 (blood, occult; feces, 1-3 simultaneous determinations) should be used.

Editors Note: For more information on coding for FOBTs, see cover article, Increase Reimbursement by Properly Coding FOBTs in the September issue of GCA.

For many local carriers, V76.49 (screening for other malignant neoplasm) is the preferred ICD-9 diagnosis code to use for these screenings, but you should check with your particular carrier to find out what it requires.

Another issue with FOBT depends on whether its an in-office test done during a rectal exam by the gastroenterologist or a take-home test where the patient is given sample cards to return to the office. The language of Medicare national policy, which states that the beneficiary completes it [fecal-occult blood test] by taking samples from two different sites of three consecutive stools, seems to indicate that it needs to be a take-home test to be eligible for reimbursement.

Editors Note: Answers to this issues coding questions were provided by Kathryn L.Cianciolo, MA, RRA, CCS, CCS-P, past chair of the Society for Clinical Coding and an independent coding consultant in Wisconsin.