Gastroenterology Coding Alert

Due to recent publicity campaigns about the effectiveness of preventive screenings for colorectal cancer, more patients are going to gastroenterologists and requesting a screening colonoscopy. For many of these patients, the screening colonoscopy will not be covered by Medicare because they do not exhibit any signs or symptoms that would qualify them for a diagnostic colonoscopy (45378) or a personal/family history of colon cancer that would qualify them for a high-risk screening colonoscopy (HCPCS code G0105 for Medicare patients). In addition, many commercial insurers do not have a screening benefit for high- or average-risk patients. Gastroenterologists are beginning to question how they should best handle the special billing and coding dilemmas posed by these average-risk screening colonoscopies.

Assessing Colorectal Screenings

According to the Medicare Carriers Manual (MCM) section 4180.1, Medicares coverage of colorectal screening tests for asymptomatic patients includes the following procedures:

Screening fecal-occult blood tests are covered at a frequency of once every 12 months for beneficiaries who have attained age 50;

Screening flexible sigmoidoscopies are covered at a frequency of once every 48 months for beneficiaries who have attained age 50;

Screening colonoscopies are covered at a frequency of once every 24 months for beneficiaries at high risk for colorectal cancer. While the specific diagnosis codes covered for a high-risk screening colonoscopy vary from carrier to carrier, individuals with a family or personal history of colorectal cancer or who have inflammatory bowel disease are generally considered to be at high risk; and

Screening barium enema examinations are covered as an alternative to either a screening sigmoidoscopy or screening colonoscopy examination. The same frequency parameters specified in the screening sigmoidoscopies or colonoscopies apply.

Average-risk Screenings Are Not Paid by Medicare

Recent literature [in the New England Journal of Medicine] has shown that colonoscopy is effective in decreasing mortality from colon cancer. Flexible sigmoidoscopy [a benefit to average-risk Medicare patients] is also effective but misses growths in the right colon, explains Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel. There are some individuals in the public eye, such as Today show host Katie Couric, who advocate average-risk screening colonoscopies beginning at age 40.

Although there is a HCPCS code (G0121, colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for reporting average-risk screening colonoscopies, this is not a benefit covered by Medicare or most commercial insurers, which means the patient usually must pay. Patients presenting with a request to have an average-risk screening colonoscopy must be made aware of insurance coverage consequences, Weinstein says. Ultimately, the patient must decide if the expense is worth the added screening thoroughness and piece of mind.

Patients Need Claim Filed for Secondary Insurance

Some Medicare beneficiaries, however, may insist that gastroenterologists file a claim for the screening procedure even though this is not a covered benefit so Medicare can file a claim with a secondary insurer. For these purposes, Medicare wants providers to use G0121 to report the average-risk screening procedure. But it is the beneficiary who is liable for payment, according to Christine Martin, CPC, practice manager at Commonwealth Gastroenterology Associates, a three-physician practice in Lexington, Ky. The MCM section 4180.2 states conclusively that providers should use G0121 to allow claims to be billed and denied for beneficiaries who need a Medicare denial for other insurance purposes.

Although neither Medicares national policy nor any local carrier specifies a diagnosis code for use with G0121, Martin suggests reporting either V76.41 (special screening for malignant neoplasms; rectum) or V76.49 (special screening for malignant neoplasms; other sites).

The 2001 ICD-9 manual has added V76.51 (special screening for malignant neoplasms; colon), which Martins practice may begin to use in these situations as well. She has already noticed that a Part A local medical review policy on colorectal cancer screenings recently issued by her local carrier, AdminaStar, now requires that this new diagnosis code be used in several screening situations.

Bill for Diagnostic Procedure If There Is a Polyp

Another coding complication can arise if a polyp is found and biopsied or removed during an average-risk screening procedure: Medicare has never directly stated whether the procedure remains a screening service or becomes a diagnostic colonoscopy, which would then be reimbursed. If a polyp is found and removed during an average-risk screening, report the appropriate diagnostic procedure code. This recommendation is in MCM section 4180.1, which states that if during the course of the screening colonoscopy a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than G0105, which is the HCPCS code for a high-risk screening colonoscopy.

For example, if a polyp is found and removed with the snare technique, 45385 (colonoscopy, flexible, proximal to splenic flexure; with removal of tumor[s], polyp[s], or other lesions[s] by snare technique) should be reported. In addition, Martin recommends using a diagnosis code that specifies the polyp finding, such as 211.3 for a colonic polyp or 211.4 for a rectal polyp, instead of or in addition to the V codes used to report the screening.

Concern Over Hemorrhoid Diagnosis

Many Gastroenterology Coding Alert subscribers have indicated that they would also like to report a diagnostic procedure code when there is a non-polyp finding, such as hemorrhoids. Reimbursement for the diagnostic procedure with a hemorrhoid diagnosis will probably be denied by Medicare, according to Kimberly Turner, a coding specialist who works with 18 gastroenterologists and eight pediatric gastroenterologists at the University of Pittsburgh Physicians.

Turner agrees that once a polyp is found the diagnostic procedure code should be used instead of the average-risk screening code. She would continue to use the average-risk screening code if the finding were a hemorrhoid. If a hemorrhoid is found during a screening colonoscopy, I would report the screening code because hemorrhoids are not a covered diagnosis for 45378 [or other codes in that family], she says. If the diagnosis code is not covered for 45378, use one of the screening codes. If you dont have a covered diagnosis code for a high-risk screening, you have to report the noncovered [average-risk] screening.

Not all gastroenterologists or coders, however, believe that a diagnostic procedure code can be reported if there is a finding for an average-risk screening. [This] is not the same as performing a procedure for a covered indication (high-risk) and submitting a finding that is also covered, Weinstein says. [In this situation,] I have advised coders to submit G0121 and only V76.49.

Use CPT Code With Commercial Payers

When it comes to commercial payers, reporting and reimbursement for average-risk screening colonoscopies become even more complicated because most commercial payers dont recognize the HCPCS G codes. We were told by Blue Cross Blue Shield not to use the G code, says Martin. Instead, we use the appropriate CPT code along with the most accurate ICD-9 V code or symptom code.

Both Martin and Weinstein recommend gastroenterologists have patients sign an ABN acknowledging the patients financial responsibility in case the commercial insurer denies the claim.

Note: Stacy Maloney, CPC, medical coder at Commonwealth Gastroenterology Associates, a three-physician practice in Lexington, Ky., also contributed to this article.