Gastroenterology Coding Alert

Question: Will Medicare pay for a screening
contrast barium enema as an alternative to a
flexible sigmoidoscopy?

Loretta DelRio
Oregon

Answer: Under the provisions of the Balanced Budget Act of 1997, Medicare will reimburse a screening contrast barium enema, single or double contrast (G0106), as an alternative to a flexible sigmoidoscopy for beneficiaries over the age of 50 who are not considered at high risk for developing colorectal cancer. The barium enema must be ordered in writing by an attending physician who has determined that it has an estimated screening potential equal to or greater than the screening potential estimated for a flexible sigmoidoscopy for that individual.

The allowed frequency for an individual not at high risk is every 48 months. The sigmoidoscopy must be performed by a doctor of medicine or osteopathy.

For beneficiaries who are considered at high risk for colorectal cancer, Medicare also will reimburse a screening barium enema as an alternative to a screening colonoscopy (G0105). But the code to use to report the screening barium enema in this case is G0120 (colorectal cancer screening, alternative to G0105, screening colonoscopy, barium enema).

The allowed frequency for an individual at high risk is every 24 months. Payment is not allowed for both a screening barium enema and one of the screening endoscopies during these screening intervals.

One of the keys to reimbursement for these screening procedures is to use the correct diagnosis code to indicate a beneficiary at average risk for colorectal cancer and one who is at high risk. Although these will vary significantly from state to state, most carriers will accept V76.41 (special screening for malignant neoplasm of the rectum) as appropriate for beneficiaries at average risk.

To report individuals at high risk for colorectal cancer, most carriers will accept the Health Care Financing Administrations recommended list of ICD-9 codes:

555.0 regional enteritis of small intestine
555.1 regional enteritis of 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
V10.05 personal history of malignant neoplasm of
large intestine
V10.06 personal history of malignant neoplasm of rectum, rectosigmoid junction and anus

Information for this reader question was provided by Pat Stout, CMT, CPC, an independent gastroenterology coding consultant in Knoxville, Tenn.