Gastroenterology Coding Alert

Question: We occasionally have patients who will be receiving liver transplants and are sent to us for a screening colonoscopy. This is done as part of a pretransplant evaluation to rule out any underlying carcinomas. Should we bill these as routine screenings if the patient is asymptomatic? Or are there more appropriate procedure and diagnostic codes to use?

Texas Subscriber

Answer: While many surgeons and hospitals often require that their patients undergo a battery of pre-operative evaluation tests and procedures, many times these are not covered by either Medicare or commercial insurers. Gastroenterology office managers should always have those patients sign a waiver acknowledging financial responsibility for all preoperative evaluation services.

Note: To download the new Medicare
advanced beneficiary notice [ABN] go to
www.hcfa.gov/regs/pdract95.htm and click
on April 19,2001.

You should check the medical policies of your various insurers, but it is unlikely that they will cover a pre-operative diagnosis such as V72.83 (other specified pre-operative examination) for a colonoscopy. Its also unlikely that the diagnosis that is causing the patient to require a liver transplant, such as cholangitis (576.1), is a covered indication.

If the patient has GI symptoms such as blood in stool (578.1) or functional diarrhea (564.5), which are covered indications for a colonoscopy, those symptoms should be reported as the primary diagnosis. The procedure will probably be reimbursed by the insurer.

With patients who are covered by commercial insurers, you have to report the diagnostic colonoscopy code (45378), whether they have symptoms or not.

For Medicare patients who are asymptomatic, however, you should see if they are covered under one of Medicares colorectal cancer screening provisions. If the patient has a family or personal history of colorectal cancer, he might qualify as a high-risk individual who is eligible for a covered screening colonoscopy (HCPCS code G0105) every 24 months.

If the patient is a Medicare beneficiary who is not at high risk and otherwise asymptomatic, report the colonoscopy with HCPCS code G0121. Effective July 1, 2001, average-risk patients are eligible for a covered screening colonoscopy once every 10 years.