Gastroenterology Coding Alert

Question: If a patient with a commercial insurer has a screening colonoscopy, I should report a diagnostic colonoscopy code. When a Medicare patient has a screening colonoscopy, I should report a G code. Is that correct?

Montana Subscriber

Answer: Your answer is correct, but you missed one important point. Coders should report all colorectal cancer screenings to private payers as diagnostic colonoscopies (45378, Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]).
 
However, when a Medicare patient has a screening colonoscopy, you must choose between a pair of G codes, depending on the patient.
 
If the patient is at average risk for colorectal cancer, he is entitled to a Medicare-covered screening once every 10 years after he reaches age 50. Report these screenings with G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).
 
Medicare patients over 50 at high risk for colorectal cancer can have a covered screening every two years. Report high-risk Medicare screenings with G0105 (Colorectal cancer screening; colonoscopy on individual at high risk).
 
G0105 warning: You're not likely to have a G0105 claim accepted without proving medical necessity. Some ICD-9 codes that Medicare carriers consider indicators of high risk of colorectal cancer 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
   555.0 - Regional enteritis of small intestine. Medicare has no national determination for G0105, so be sure to consult your local medical review policy for approved G0105 diagnosis codes.