Gastroenterology Coding Alert

Question: I am aware that Medicare will pay more frequently for screening colonoscopy for patients at -high risk.- But what factors qualify as -high risk-?


Missouri Subscriber

Answer: You are correct that Medicare will pay for screening colonoscopy G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) once every two years for individuals aged 50 or older at -high risk---but it will pay for the service only once every 10 years for patients 50 or older at -average risk.- Obviously, then, how you document the patient's risk level can have an important effect on your coding and reimbursement.

Unfortunately, there is no uniform definition of -high risk.- Still, there are some widely accepted indicators of high colorectal cancer risk in a patient. The most common include family history of colorectal cancer and family history of adenomatous polyposis, as well as inflammatory bowel disease, Crohn's disease or ulcerative colitis.

Some of the ICD-9 codes that Medicare carriers consider indicators of diagnoses of high risk in a patient include:

- V10.05--Personal history of malignant neoplasm; gastrointestinal tract; large intestine
- V12.72--Personal history of certain other diseases; diseases of digestive system; colonic polyps
- V16.0--Family history of malignant neoplasm; gastrointestinal tract
- V18.5--Family history of certain other specific conditions; digestive disorders; colon polyps
- 555.0--Regional enteritis of small intestine.

Be sure: Because payers vary, you should review your Medicare payer's local coverage decision (LCD) on G0105 to get the most recent list of approved diagnosis codes that identify patients at high risk of colorectal cancer. Remember, however, that you must code from the documentation, not simply assign a diagnosis that will get you paid--which could quickly lead to fraud charges.

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Lawrenceville, Ga.