Billing colorectal cancer screenings for asymptomatic patients can be confusing for many gastroenterologists because each state Medicare carrier seems to have its own rules concerning how to bill for these procedures. Although Medicare coverage of various colorectal cancer screening examinations was enacted with the passage of the Balanced Budget Act of 1997, gastroenterologists need to be precise in their use of ICD 9 diagnostic and HCPCS codes when they bill for these procedures to maximize reimbursement.
Medicares coverage of colorectal screening tests for asymptomatic patients includes the following procedures furnished to an individual for the early detection of cancer:
- Screening fecal-occult blood tests are covered at a frequency of once every 12 months for beneficiaries who have attained age 50.
- Screening flexible sigmoidoscopies are covered at a frequency of once every 48 months for beneficiaries who have attained age 50.
- Screening colonoscopies are covered at a frequency of once every 24 months for beneficiaries at high risk for colorectal cancer.
- Screening barium enema examinations are covered as an alternative to either a screening sigmoidoscopy or screening colonoscopy examination. The same frequency parameters specified in the screening sigmoidoscopies or colonoscopies apply.
A patient must fall into the high-risk category for colorectal cancer to qualify for a screening colonoscopy or screening barium enema. For a patient to be classified as high risk, you have to use a certain diagnosis, says Peg Hopwood, supervisor of patient accounts for Rockford Gastroenterology, a practice of nine gastroenterologists in Rockford, Ill. You dont get paid just because the patient has colorectal cancer screening as a benefit.
HCFAs Two Definitions of High Risk
The Health Care Financing Administration (HCFA) states that high risk for colorectal cancer means an individual with one or more of the following:
-a close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyposis;
- a family history of familial adenomatous polyposis;
- a family history of hereditary nonpolyposis
- a personal history of adenomatous polyps;
- a personal history of colorectal cancer; or
- inflammatory bowel disease, including Crohns
disease and ulcerative colitis.
To be reimbursed for the screening, gastroenterologists must include an accepted diagnosis code denoting the high-risk status of the patient with the procedure code. HCFA states that the following ICD 9 Codes are examples of diagnoses that meet the high-risk criteria for colorectal cancer:
- V10.05personal history of malignant neoplasm of
- V10.06personal history [...]