Colonoscopy: 45378, G0121, G0105: Score Medicare Pay with These FAQs
Check diagnosis, risk level for medical necessity.
Colonoscopy for cancer screening won't garner Medicare pay -- unless you follow frequency guidelines and eligibility requirements to the letter. Make sure you get all the colorectal cancer screening pay you deserve for your general surgery practice using these FAQs.
Who's Eligible for Average-Risk Test?
If the Medicare patient is 50-plus years old, he is eligible for a covered Medicare screening, explains Dena Rumisek, CPC, a biller in Grand Rapids, Michigan.
However: These patients are considered average risk, and can have a colorectal cancer screening only once every 10 years, says Cheryl Ray, CCS, CPMA, of Atlantic Gastroenterology in Greenville, N.C.
"Medicare is very stringent on the date ... it has to be 10 years or longer -- it can't be 9 years and 360 days," between covered screening colonoscopies, confirms Rumisek.
Example: A 68-year-old established Medicare patient reports for a screening colonoscopy on Dec. 5, 2010. The patient's records indicate that he last had a covered screening on Sept. 15, 1999. On the claim, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).
What ICD-9 Codes Are In Play for G0121?
Just one code justifies G0121 -- provided there is no need for any therapeutic intervention during the colonoscopy. Medicare requires V76.51 (Special screening for malignant neoplasms; colon) on all G0121 claims. You might list other identified conditions secondarily, including diverticulosis (562.10) or hemorrhoids (455.0).
Always list the V code first for an average-risk screening, however.
What if the Patient Had a Recent Flexible Sig?
The frequency rules differ depending on whether other related colorectal cancer tests were performed previously; if a patient has had a routine flexible sigmoidoscopy screening (G0104, Colorectal cancer screening; flexible sigmoidoscopy), he is not entitled to a screening colonoscopy for at least 48 months, advises Cynthia Swanson RN, CPC, senior managing consultant for Seim, Johnson, Sestak & Quist LLP in Omaha, Neb.
Example: An average-risk established Medicare patient reports to the surgeon for a screening colonoscopy on Dec. 7, 2010. The patient's medical record indicates that he had a flexible sigmoidoscopy screening on Nov. 17, 2008. This patient is not now eligible under Medicare guidelines for a screening colonoscopy because it has been only three years since his sigmoidoscopy.
What About Coverage for High-Risk Patients?
A patient who is considered at high risk for colorectal cancer is entitled to a screening colonoscopy once every 24 months, Ray says. "High risk" includes factors such a personal history of colon cancer, inflammatory bowel disease, or adenomatous polyps, or a family history of familial adenomatous polyposis or nonpolyposis colorectal cancer. You'll list a V code (such as V10.05 [History of colon cancer] or V12.72 [Diseases of digestive system; colonic polyps]) as the primary diagnosis for these tests.
If the patient already suffers from a condition that automatically put him at high risk for colorectal cancer, list that condition as the primary diagnosis.
Example: A 69-year-old established Medicare patient with a personal history of colonic polyps reports to the surgeon for a colonoscopy screening on Dec. 1, 2010. The patient record indicates that the patient's last colonoscopy screening was May 4, 2007. On the claim, report G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) with V12.72 appended.
Can I Bill Private Payers for Screenings?
The answer will vary. Some private payers reimburse fully for colonoscopy screenings -- their coding practices for these services can differ from Medicare, however. Many U.S. states have passed legislation similar to the Medicare regulations requiring all health insurance payers to cover routine colorectal cancer screening starting at age 50.
Most non-Medicare payers accept 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing; with or without colon decompression [separate procedure]) for a screening colonoscopy, Ray relays.
What Happens When Screening Turns Diagnostic?
You should report the proper CPT code based on the encounter notes, Swanson confirms. Remember, the Medicare G codes are for screenings only. "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 G0105," according to the Medicare Benefit Policy Manual (280.2.2.C).
Example: A 67-year-old Medicare patient at average risk for colorectal cancer reports to the surgeon for a scheduled screening colonoscopy. During a complete screening colonoscopy to the cecum the surgeon identifies and removes a pair of polyps from the ascending colon using hot biopsy forceps. The pathology demonstrates that these were both benign.
In this example, you'll report 45384 (Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor([s)], polyp[s)], or other lesion([s)] by hot biopsy forceps or bipolar cautery) with 211.3 (Benign neoplasm of other parts of digestive system; Colon). You would not bill G0105.
Use new modifier PT: For Medicare contactors, providers should append modifier PT (Colorectal cancer screening test converted to diagnostic test or other procedure) "to the diagnostic procedure code that is reported instead of the screening [test] when the screening test becomes a diagnostic service," according to the Medicare Physician Fee Schedule Final Rule published in the Nov. 29, 2010 Federal Register. In the above example, that means reporting 45384-PT.
That's good news for beneficiaries, and therefore for providers, because Medicare will respond to the modifier by waiving the deductible for all surgical services on the same date as the diagnostic test.
Source:General Surgery Coding Alert