Gastroenterology Coding Alert

Carriers are free to require a different diagnosis code for "average-risk" patients, so you should look for announcements from your local carrier regarding specific diagnosis codes they will accept. Also, be aware that Medicare Carriers Manual section 4180.2 (D) states, "If the patient would otherwise qualify to have a covered G0121 screening colonoscopy performed but has had a covered screening flexible sigmoidoscopy (G0104), then he or she may have a covered G0121 screening colonoscopy only after at least 47 months have passed following the month in which the last covered G0104 flexible sigmoidoscopy was performed."

You should report G0121 for the patient you described if the patient has Medicare coverage, while making sure to check with the carrier to find covered diagnosis codes. To be safe, you can ask the patient to sign an advance beneficiary notice (ABN) to inform the patient that he or she must pay for the procedure if Medicare does not cover it because of frequency regulations or other problems. For non-Medicare patients, you should report CPT code 45378 (Colonoscopy, flexible ...) and the ICD-9 diagnosis code V76.51. Coverage of average-risk screening colonoscopy for non-Medicare patients is highly variable depending on state regulations and specific health insurance policies.