General Surgery Coding Alert

Medicare guidelines generally require that a screening exam is a covered benefit for Medicare beneficiaries at low risk for colorectal cancer only for those patients 50 years of age or older. This can vary, however, and some carriers specify medical-necessity requirements that allow low-risk beneficiaries under age 50 to receive a covered screening exam.

For beneficiaries at high risk for colorectal cancer, national Medicare policy does not set a minimum age requirement. "For beneficiaries considered to be at high risk for developing colorectal cancer, Medicare covers one screening colonoscopy every two years, regardless of age," according to MedLearn Matters article SE0613.

Tip: You might still have trouble getting G0105 claims paid for patients younger than 50. If you get a denial on a G0105 claim because the patient is under 50, contact the carrier, and reference the above-mentioned MedLearn Matters article.

Example: The high-risk patient in the example above returns one week after the attempted but unsuccessful screening exam. On this occasion, the surgeon successfully inserts the scope and fully visualizes the colon past the splenic flexure.

You have already reported the initial exam using G0105-53, for which you will receive reimbursement equivalent to that of a flexible sigmoidoscopy. For the second, successful exam, you would report G0105 once again, this time without a modifier. Medicare guidelines dictate that your surgeon will be paid in full for the second exam at the standard fee schedule rate.

Resource: You can view Transmittal AB-03-114 at http://www.cms.hhs.gov/Transmittals/Downloads/AB03114.pdf.

On occasion, an asymptomatic patient may request a colonoscopy that does not meet Medicare screening requirements. In such cases, your best bet to collect payment is to bill the patient directly for the service.

For instance: A covered Medicare patient under the age of 50 with no apparent symptoms and low-risk factors may ask for a screening "just to be sure," or a high-risk beneficiary who has had an exam within 18 months may request an exam for similar reasons.

To ensure that the patient understands that he will be responsible for payment, you should request that he read and sign an advance beneficiary notice (ABN). You should present the patient with the ABN well in advance of the procedure and explain to the patient why Medicare will likely deny the service.

"An ABN tells the patient it's likely that Medicare won't cover the service, and therefore it will be the patient's responsibility to pay if the service is uncovered," says Cecile M. Katzoff, MGA, vice president for consulting services at the American Gastroenterological Association and the director of the AGA Center for GI Practice Management and Economics. "The patient can then determine whether or not he wants to have the procedure done, given the fact it's likely he will have to pay for it."

Medicare does not mandate that you use ABNs, but it does prohibit billing a Medicare beneficiary for a denied claim unless the doctor's office has a signed ABN. The ABN proves to Medicare that the patient understands that he might be responsible for the bill, Katzoff says.-

Resource: You can find a sample ABN form on the CMS Web site at http://www.cms.hhs.gov/cmsforms/downloads/cmsr-131-g.pdf.