General Surgery Coding Alert

As of July 1, 2001, Medicare will cover screening colonoscopies every 10 years for patients not at high risk for colorectal cancer. In a Feb. 8 transmittal (No. 1697, change request 1536), HCFA announced that section 4180.2-4180.9 of the Medicare Carriers Manual would be changed to indicate that HCPCS code G0121 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) should no longer be a noncovered service.

Note: Individuals who have had a covered flexible sigmoidoscopy (G0104) must wait four years before undergoing a screening colonoscopy.

Until now, Medicare only covered screening colonoscopies (once every 24 months) for beneficiaries at high risk for colorectal cancer. These screenings are coded G0105 (colorectal cancer screening; colonoscopy on individual at high risk).

To qualify as high risk, a patient must meet one or more of the following conditions:

A close relative (sibling, parent, or child) has had colorectal cancer or an adenomatous polyposis

A family history of familial adenomatous polyposis

A family history of hereditary nonpolyposis colorectal cancer

A personal history of adenomatous polyps, or a personal history of colorectal cancer

Inflammatory bowel disease, including Crohns disease, and ulcerative colitis.

An appropriate diagnosis code indicating one or more of the above conditions should be linked to G0105 on the HCFA claim form.

A single diagnosis code, V76.51 (special screening for malignant neoplasms; colon), is available for colonoscopies for patients at low risk. This V code must be linked to G0121 on the claim form, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. If a sign or symptom such as abdominal pain is used, the screening colonoscopy claim will likely be denied, she notes.

If the screening detects a problem but no other procedure is performed, the diagnosis initially coded cannot be altered after the fact to reflect the new problem. For example, if the screening colonoscopy indicates that the patient has diverticulosis, only the screening diagnosis (V76.51) may be used. And, for some Medicare carriers, only the screening diagnosis and not the diverticulosis (562.10) diagnosis should be used even if the surgeon subsequently counsels the patient on healthier eating habits and lifestyles.

Other Medicare carriers have stated in their bulletins that if the diverticulosis is more than incidental (i.e., significant) and some form of treatment (which would include dietary counseling, for instance) is provided, the colonoscopy becomes a diagnostic procedure and diverticulosis may be used as the supporting diagnosis.

All Medicare carriers agree, however, that if during the course of the screening colonoscopy a lesion or growth is detected that results in a biopsy or removal of the growth, the appropriate code for the therapeutic procedure (for example, 45380, [...]