General Surgery Coding Alert

Question: In General Surgery Coding Alert Vol. 10, No. 6, pp. 43-46, you advised that Medicare will cover a colorectal cancer screen once every 10 years for average-risk patients age 50 or older. I have heard that there are exceptions to this rule for patients who have received a previous sigmoidoscopy. Is this correct?

New Jersey Subscriber

Answer: A previous sigmoidoscopy may change a patient's eligibility for a Medicare-covered screening colonoscopy.

If your patient has had a Medicare-covered cancer screening via flexible sigmoidoscopy (G0104, Colorectal cancer screening; flexible sigmoidoscopy) within the last 48 months, he is not eligible for a colonoscopy screening. According to Medicare, average-risk patients who have had covered flexible sigmoidoscopy screenings must wait four years before having a covered colonoscopy screening (G0121, Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk). Therefore, if an average-risk Medicare patient had a flexible sigmoidoscopy screening on May 5, 2004, he would not be eligible for a covered screening colonoscopy until at least May 5, 2008.

-- Technical and coding advice for You Be the Coder and Reader Questions provided by Marcella Bucknam, CPC, CCS-P, CPC-H, CCS, CPC-P, CPC-OBGYN, CPC-CARDIO, manager of compliance education for the University of Washington Physicians and Children's University Medical Group Compliance Program.