General Surgery Coding Alert

HCFA pays for some colonoscopy screenings, but reimbursement is often difficult to obtain. Detailed and complex criteria must be met in order to qualify for Medicare reimbursement, and HCFAs regulations depend, in large part, on whether the patient has a family or personal history of colon problems.

For example, HCFA permits individuals at risk for colon problems to receive a colonoscopy screening every two years, while those without family or personal history are not eligible at all. According to HCPCS 1999, Medicares National Level II Codes, the screening on patients at risk for colon problems is coded G0105, while the procedure on patients deemed not at risk is coded G0121. Medicare will reimburse for a G0105 claim, but does not accept G0121. (See box for colonoscopy code descriptions below.) If, however, the colonoscopy is performed because the patient does have symptoms, you would bill CPT code 45378 (diagnostic colonoscopy).

HCFAs criteria for determining which individuals are at risk are quite specific, according to Kathleen Mueller, RN, CPC, CCS-P, a physician reimbursement specialist who currently consults with Allan L. Liefer, MD, FACS, a general surgeon in Chester, IL.

If the patient is asymptomatic, the only patient diagnoses HCFA will recognize are inflammatory bowel disease (555.0-555.9) and ulcerative colitis (556.0-556.9).

HCFA also will recognize personal history of cancer (V10.05-V10.06, malignant neoplasm); personal history of colon polyps (V12.72 colonic polyps); family history of cancer (V16.0, family history of malignant neoplasm; V18.5 both family history of gastrointestinal disease and family history of colon polyps).

In addition, at least 23 months would need to have passed since the patients last colonoscopy screening. Any non-screening colonoscopies that may have been performed do not count and need not be considered. According to Mueller, many surgical coders bill this incorrectly because they do not differentiate between screenings and diagnostic/surgical colonoscopies.

The GA Modifier Waives Medical Necessity

It is also possible, though unlikely, that Medicare will not reimburse the normally allowable screening the G0105 for one of the following two reasons:

Another screening was performed within the last 23 months.
The patient was misdiagnosed or the wrong diagnostic code was used.

Accordingly, the patient will be required to pay for the colonoscopy.

Before performing the procedure on the patient at-risk for denial from Medicare, the general surgeon should get the patient to sign a waiver of liability form (see sample form on page 6). It states that should a normally Medicare-covered procedure be denied, the patient agrees to be responsible for Medicares approved amount.

The waiver needs to be signed before the procedure is done, and must be signed before every such procedure. A copy of the waiver form should also included in the patients chart.

When filing the claim, the at-risk-for-denial procedure code should have the GA Modifier attached to it. This way Medicare will know that the surgeon has a liability form signed by the patient on file. If the surgeon does not have the patient sign the form before the procedure, if Medicare denies payment the doctor will have to write off the colonoscopy if Medicare.

Non-Covered Colonoscopy Screening Claims

For asymptomatic patients not considered at risk for colon problems, colonoscopy screenings that yield negative findings should be submitted to Medicare using a G0121 code, even though the procedure is not reimbursed by Medicare. Patients with no family history, no personal history and no symptoms would fall into this category.
Although no waiver is necessary, the surgeon should inform the patient requesting the colonoscopy screening that the procedure is not covered by Medicare and that he or she will have to pay for it out-of-pocket.

Informing the patient is not required by Medicare rules, because the service is not covered by Medicare, but such communication is an excellent idea. This allows the patient to know ahead of time that he or she will be required to pay for services.

The surgeon then sends in the G0121-coded procedure, which -- no surprise -- will be denied by Medicare. The patient then is informed that the procedure was denied and how much he or she must therefore pay the physician.

Cynthia Thompson, CPC, a senior consultant with Gates Moore & Company in Atlanta, GA, says that after Medicare denies the G0121, surgeons should bill the secondary payer if there is one, using CPT code 45378.

Note: The use of the GA Modifier does not apply to the G0121, because the procedure is not covered in the first place.

Coding for Private Carriers

Both the G0105 and G0121 codes are for Medicare use alone, and are used only to code colonoscopy screenings that return negative.

Should the results of the colonoscopy return positive, surgeons need to file 45378 with Medicare, the same code they would use to file with a private carrier.
Mueller also advises general surgeons to inform patients covered by private carriers that they may have to pay for the procedure, because private carriers may or may not cover preventive medical procedures, such as colonoscopy screenings.

Note: Private carriers use 45378 for all colonoscopies, whether screening or diagnostic.