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Part B Insider (Multispecialty) Coding Alert

When Is a Screening Colonoscopy High-Risk?

Published on Tue Jan 27, 2004

Keep track of anniversaries to avoid low-risk screening denials

When can you bill for a high-risk screening colonoscopy (G0105) instead of a regular screening colonoscopy ( G0121 )?
 
There are certain circumstances that Medicare considers high-risk when it comes to colon cancer. They include:
 

  •  a close relative, such as sibling, parent or child, has had colorectal cancer or an adenomatous polyp
     
  •  a family history of familial adenomatous polyposis
     
  •  a family history of hereditary nonpolyposis colorectal cancer
     
  •  a personal history of adenatomous polyps
     
  •  a personal history of colorectal cancer
     
  •  inflammatory bowel disease including Crohn's disease or ulcerative colitis.
     
    "In the absence of those diagnoses or conditions, a screening colonoscopy would not be considered high-risk," says Carol Pohlig, a coder with the department of medicine at the Hospital of the University of Pennsylvania.
     
    If a patient doesn't qualify for a high-risk screening colonoscopy, you've got another tricky tracking problem, Pohlig says. Non-high-risk patients only receive screenings every 10 years, so "unless you've been following this patient yourself, it's very difficult to have that 10-year information."

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