Primary Care Coding Alert

You Be the Coder:

Understand These Medicare Colonoscopy Criteria

Published on Wed Oct 16, 2019

Question: What documentation do we have to provide for a Medicare patient to justify a screening colonoscopy?

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Answer: The key to determining patient eligibility for a screening colonoscopy lies in your ability to demonstrate whether the patient is at a high risk for developing colorectal cancer or not.

According to the Centers for Medicare & Medicaid Services (CMS), “Medicare covers one screening colonoscopy every 10 years, but not within 47 months of a previous screening flexible sigmoidoscopy … for beneficiaries 50 and older not considered to be at high risk for developing colorectal cancer. For beneficiaries considered to be at high risk for developing colorectal cancer, Medicare covers one screening colonoscopy every two years, regardless of age.”

In addition, Medicare defines an individual at a high risk for colorectal cancer if the patient has: 

a close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;
a family history of adenomatous polyposis;
a family history of hereditary nonpolyposis colorectal cancer;
a personal history of adenomatous polyps;
a personal history of colorectal cancer; or
a personal history of inflammatory bowel disease, including Crohn’s disease and ulcerative colitis.

(Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE0613.pdf).

So, for a patient who does not meet the criteria for being at a high risk for colorectal cancer, you will need to document that the patient is at least 50 and has not had a screening colonoscopy within the last 10 years or a screening flexible sigmoidoscopy within the previous 47 months. Under these circumstances, you can justify G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

To justify G0105 (Colorectal cancer screening; colonoscopy on individual at high risk), your patient should not have had a screening colonoscopy within the past two years. In addition, your claim will need to include at least one of the conditions listed above. Some of the diagnosis codes that you can use to indicate those criteria include, but are not limited to: