Gastroenterology Coding Alert

Question: A Medicare patient who had a screening colonoscopy five years ago came in for another. How should I report the second screening? Should I have the patient sign a waiver? Connecticut Subscriber Answer: Medicare's national policy on screening colonoscopies depends on if the patient is at high risk for developing colorectal cancer. For beneficiaries who are at high risk, Medicare covers a screening every 24 months. An individual at high risk has one or more of the following:

an immediate family member who has had colorectal cancer or an adenomatous polyp a family history of familial adenomatous polyposis a family history of hereditary nonpolyposis colorectal cancer a personal history of adenomatous polyposis a personal history of colorectal cancer inflammatory bowel disease, including Crohn's disease and ulcerative colitis. 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.