Gastroenterology Coding Alert

If your patient meets the criteria for high risk, you should report G0105 (Colorectal cancer screening; colonoscopy on individual at high risk). Because the screening is performed within Medicare's allowable time frame, Medicare will pay for this service.

On July 1, 2001, Medicare expanded its coverage for beneficiaries not at high risk to allow a screening colonoscopy once every 10 years. Regardless of coverage, if the patient is at low risk, Medicare will not cover another screening colonoscopy for 10 years. Therefore, the patient is ineligible for G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) until 2006.

Similarly, if the patient had a screening flexible sigmoidoscopy (G0104, Colorectal cancer screening; flexible sigmoidoscopy) within the last 47 months, he or she is ineligible for coverage of a screening colonoscopy. Check the patient's records and question him on his medical history.

You should obtain an advance beneficiary notice (ABN) for all Medicare patients who have a screening examination (high- or low-risk). The ABN should state that Medicare may deny the service and why. You should append modifier -GA (Waiver of liability statement on file) to the appropriate screening code. If Medicare denies coverage, you can bill the patient.