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Medicare Referral to GI for Colonoscopy on High Risk Pt (sister has colon cancer

Stacy Posted Wed 04th of January, 2017 18:34:19 PM
Medicare "Referral" to GI for Colonoscopy because patient's sister has colon cancer: This is a new Medicare patient sent to the GI physician and the reason for the referral from the primary care physician is for patient to have a colonoscopy. Can a new patient visit code be billed for the assessment and decision to proceed to a colonoscopy in 2 weeks?
SuperCoder Answered Thu 05th of January, 2017 01:38:08 AM

If a patient is seen in the office prior to a screening colonoscopy with no GI symptoms and who is otherwise healthy, then a visit prior to a screening colonoscopy is not billable. Also, if the patient is otherwise healthy, CMS guidelines state that one should not report an E/M with the screening colonoscopy. Only if the patient needs a detailed E/M service supported by documentation of a medically-necessary history, exam, and diagnoses, one may bill a separate E/M code with modifier 25. Please refer to the following CMS link for more details. Thank you.

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c18.pdf

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