Gastroenterology Coding Alert

Question: A Medicare patient has a family history of colon cancer. Five years ago, the patient underwent a colonoscopy screening and our physician performed another one recently. Medicare will not pay for the most recent screening. The patient had no symptoms, but we thought that Medicare would pay if the patient was high risk. We have tried codes 45378 and G0121.

Maryland Subscriber

Answer: The correct procedure code is G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) and the primary diagnosis should be V16.0 (Family history of malignant neoplasm; gastrointestinal tract).

The code G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) is for patients who are not high risk, and Medicare will only pay for such a screening once every 10 years.

Check to see how that colonoscopy screening was submitted five years ago. If it was coded G0105, and you resubmit the recent claim with the correct codes, Medicare should pay. According to the Medicare Benefit Policy Manual, Medicare will pay for screening colonoscopies for beneficiaries at high risk of developing colorectal cancer when performed once every 24 months. However, theAmerican Cancer Society and all of the gastroenterology societies (AGA, ASGE, ACG) recommend a five-year interval for follow-up of patients with a family history of colorectal cancer.

Watch out: If during the course of the screening colonoscopy, the physician biopsies or removes a growth,you code the appropriate diagnostic procedure rather than G0105.