Wiki When Can I bill G0105 for a patient that finally has a clean surveillance of polyps?

FUTURE09

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Hello,
I'm a seasoned CPT coder for over 28 years but just took a Billing Manager position at a GI practice in July 2018. I have spent many hours reading as many resources as I can get my hands on in regard to our high risk patients and when can I bill for a G0105.

Patient come in for a preventative screening and polyps are found and removed. I bill the appropriate CPT 40000 series and add my PT/33 modifier, using the Z12.11 diagnosis followed by the polyp diagnosis. Physician notes to schedule a surveillance screening in 3-5 years, accordingly to the CRC frequency. Patient comes in for surveillance (indication for surveillance screening) and we find no polyps. I then bill out the appropriate CPT 40000 series with DX Z09 and HX of polyps Z86.010. Physician then states again surveillance in 3-5 years.

This is where my confusion is coming in. When the high risk patient comes back and again there are no polyps can I bill the G0105 with DX Z12.11, Z86.010? Or does a high risk patient with hx of polyps never get assigned the G0105? My thought process is, we are trying to report that clean preventative screening on a patient that had polyps but now is clean.

I am out of resources and find myself in a state of frustration. I would so appreciate any advisement or directive.

Sincerely,
Kim Kovach, CPC
 
I would have billed G0105 for the 2nd procedure with diagnosis Z86.010 if no biopsy or removal of polyp was done, this would be the appropriate procedure code to use each time if it does not become diagnostic. You would never bill G0105 with Z12.11. G0121 would be assign for Z12.11 after 10 years and no polyps have been noted.
 
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