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DOCUMENTATION REQUIRED TO CODE HIGH RISK COLONOSCOPY

Charlene Posted Wed 18th of September, 2019 11:43:20 AM
The following is typical op note documentation by our physicians for patients returning for surveillance colonoscopy (24 months or greater): Preoperative Dx: personal history of colon polyp, Postoperative Dx: personal history of colon polyp (When no pathology found on exam.), Procedure: COLONOSCOPY. The dx and timeline do fit Medicare and other insurance requirements for high risk screening colonoscopy (G0105). My question is: MUST the physician document the procedure as SCREENING COLONOSCOPY in order to meet coding guidelines and assign G0105 to this procedure? If you could point me to specific CPT or Medicare guidance I would appreciate it, as this is needed as evidence to establish workflow protocol.
SuperCoder Answered Thu 19th of September, 2019 03:20:23 AM

Hi,

 

As per CMS guidelines, screening colonoscopies (code G0105) may be paid when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered G0105 screening colonoscopy was performed).

 

Medicare considers an individual potentially at 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 familial adenomatous polyposis
     
  • a family history of hereditary nonpolyposis colorectal cancer
     
  • a personal history of adenomatous polyps
     
  • a personal history of colorectal cancer
     
  • inflammatory bowel disease, including Crohn's disease and ulcerative colitis.

 

NOTE: If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than code G0105.

 

When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances, Medicare will pay for the interrupted colonoscopy as long as the coverage conditions are met for the incomplete procedure.

 

Please also check below link (page no. 4):

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/r52cp.pdf

 

Hope this helps!

 

 

Thanks

 

Charlene Posted Thu 19th of September, 2019 08:32:43 AM
Thank you for the information, however, I need to know if the word SCREENING must be documented in the procedure in order to met coding guidance before assigning G0105. Is there anything in writing (maybe from AAPC) that dictates this guideline one way or the other?
SuperCoder Answered Fri 20th of September, 2019 05:19:58 AM

Hi,

 

Many providers are confused about the definition of screening because the codes can vary between average-risk screening and for high-risk screening. If the provider does not make the patient’s risk status clear in the report then mistakes may occur with claims, so it necessary to mention in report for which type of screening is patient coming for.

 

As per Medicare, a screening is a procedure done on the patient when he is asymptomatic and there are no symptoms or abnormalities. It is performed to rule out the possibility of a pathology such as cancer.

According to Medicare, an individual with a strong positive family or personal history of cancer, colorectal cancer, adenomatous polyp, or one who has Crohn’s disease, ulcerative colitis, or Inflammatory Bowel Disease (IBD) is at high risk for developing colorectal cancer, and is a candidate for screening.

 

Please also check below links:

https://www.supercoder.com/coding-newsletters/my-part-b-coding-alert/part-b-coding-coach-4-tips-help-you-claim-colorectal-cancer-screening-payment-149092-article

https://www.supercoder.com/coding-newsletters/my-part-b-coding-alert/part-b-coding-coach-frequency-is-a-factor-when-coding-colonoscopies-151480-article

https://www.supercoder.com/coding-newsletters/my-part-b-coding-alert/part-b-coding-coach-get-the-scoop-on-how-to-code-all-types-of-colorectal-screenings-159374-article

>https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=52378&ver=42&SearchType=Advanced&CoverageSelection=Local&ArticleType=BC|SAD|RTC|Reg&PolicyType=Both&s=All&CptHcpcsCode=g0105&kq=true&bc=IAAAACAAAAAA&

 

Hope this helps!

 

Thanks

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