Gastroenterology Coding Alert

Question: A patient comes into the office and wants a colonoscopy screen. He cites a family history of colon polyps as a matter of concern. Is this family history sufficient for choosing a V code diagnosis and for reimbursement for a colonoscopy? If so, which code should I use?

Idaho Subscriber Answer: Generally, a history of colon polyps will not provide a sufficient diagnosis to gain reimburse-ment, especially from most Medicare carriers. However, this does vary from state to state and carrier to carrier, so check with your local carriers to verify what, if any, family history code will be acceptable as a diagnosis warranting colonoscopy.
 
Coders report a variety of V codes to justify colonoscopies for patients with family history of colon polyps. Code V18.5 (Family history of certain other specific conditions; digestive disorders) is perhaps the most popular. Other codes reported to have been used include V76.50 (Special screening for malignant neoplasms; intestine, unspecified), V76.51 (... colon) and V19.8 (Family history of other conditions; other condition).
 
Many carriers will not consider these family history diagnoses as placing the patient in a high-risk category. For instance, Georgia's Medicare carrier in the Atlanta area will not pay for any of the codes above for colonoscopy. They designate the following codes as constituting high risk on the patient's behalf and thus warranting colonoscopy screen:
 
  V10.00 - Personal history of malignant neoplasm; gastrointestinal tract, unspecified
  V10.05 - Personal history of malignant neoplasm; large intestine
  V10.06 - Personal history of malignant neoplasm; rectum, rectosigmoid junction, and anus.
 
Georgia's policy lists family history of colon cancer as high risk, but the other diagnoses would not hold up. If you're submitting without the patient classifying as high risk for cancer, Medicare instructs you to "down-code": Use the HCPCS procedure code G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk), a low-risk screen.
 
Another critical factor for payment of colonoscopy for Medicare is timing. Medicare considers high-risk patients to be eligible for a colon screening every 24 months.