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Colon Screening for patient under age 50

Susan Posted Tue 18th of June, 2019 14:11:41 PM
The patient is under the age of 50 and is at high risk due to family history of CRC. Can the G Code G0105 be used with z80.0 or because the patient is under 50 and does not have screening benefits is the 45378 used with Z80.0. I was always under the assumption that if patient under age 50 the g-codes don't apply
SuperCoder Answered Wed 19th of June, 2019 04:55:53 AM

Keeping straight the differences among diagnostic (45378), high-risk screening (G0105) colonoscopies can be difficult.

Screening test can be provided to the patient in absence of signs or symptoms based on the patient’s age, gender, medical history and family history according to medical guidelines. It is defined by the population on which the test is performed, not the results or findings of the test. As such, screening describes a colonoscopy that is routinely performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps.  Whether a polyp or cancer is ultimately found does not change the screening intent of that procedure.

Screening colonoscopy can be billed for Medicare patient using G0105 (Colorectal cancer screening; colonoscopy on individual at high risk).

As described, Medicare provides coverage for screening colonoscopy every two years for beneficiaries with a high risk for colorectal cancer and for beneficiaries not at high risk once every 10 years but not within 47 months of a previous screening. Individuals at a higher risk of colorectal cancer may begin screening at a younger age to avoid any risks at a later age, hence bar of 50 years age nullified here.

Medicare considers an individual at high risk for developing colorectal cancer as one who has one or more of the following categories:

  • Close relative (Parent, Child or Sibling) who has had colorectal cancer or adenomatous polyp.
  • Family history of familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer.
  • Personal history of adenomatous polyps or colorectal cancer.
  • Inflammatory bowel disease, including Crohn’s Disease, and ulcerative colitis.

On the other hand, when reporting a screening colonoscopy for a Non-Medicare patient, report CPT code 45378 and use the appropriate screening diagnosis code, Z80.0 in your case.

Hope this helps!

Susan Posted Wed 19th of June, 2019 16:57:51 PM
Yes, this clarifies the issue. Thank you
SuperCoder Answered Thu 20th of June, 2019 02:15:06 AM

Thank you, happy to help.


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