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Joseph Posted Thu 03rd of November, 2011 13:37:45 PM

Am I correct in my thinking that a person with Medicare or any other ins. is not eligible for a colon cancer screening if they have any signs or symptoms? I thought the colonoscopy would then be a diagnostic procedure due to the signs and symptoms? For example: A Medicare patient comes to the office with a symptom such as blood in the stool or constipation etc. They have a hx of colon polyps and it's been two years since their last high risk screening. It is my thinking that based on Medicare guidelines that although this patient would be eligble for a high risk screening if he had no symptoms, his procedure would need to be done based on his signs and symptoms and not a high risk screening. Please clarify this example for me, so I can change my thinking on this or verify that I have the right understanding that screening colonoscopies are only done on patients that have no signs or symptoms regardless of the ins. carrier. Thanks for any enlightenment on this subject.

SuperCoder Answered Thu 03rd of November, 2011 21:33:07 PM

First of all we have to understand the basic difference:-
A screening colonoscopy is performed on patients who do not have signs or symptoms and there are no significant findings found during the examination.
A diagnostic colonoscopy is defined as one performed to evaluate signs or symptoms of disease.
So, as the patient is having symptoms, then the order can't be considered Screening.
Determine Whether Patients Qualify

Although Medicares national policy seems quite detailed, physicians are still unclear about what is covered. The high-risk screening benefit is one of the hardest policies to interpret, says Christine Martin, CPC, practice manager at Commonwealth Gastroenterology Associates, a three-physician practice in Lexington, Ky.

Because this Medicare policy is relatively new, many primary care physicians often are confused about what it covers, says Martin, who adds that most of her practices screening patients are referred by their PCP. Some primary care physicians, for example, look at the number of relatives as well as the closeness of the relationship when determining whether a patient is at high risk due to a family history of colon cancer. As a result, a physician might consider having a grandparent and two aunts with colon cancer to put someone at high risk, but Medicare only covers mother, father, sister, brother and child.

To make sure that the patient qualifies under Medicares specific policy for a high-risk screening colonoscopy, appointment schedulers at Martins office will ask questions about the patient when the PCPs office arranges the appointment. The questions also help the scheduler determine whether the patient has any signs or symptoms that would qualify him or her for a diagnostic colonoscopy, and when his or her last high-risk screening colonoscopy was performed.
Here is your answer:
Usually its a staff person, not a physician or nurse, who calls to arrange the colonoscopy, and that person may not know the difference between a high-risk screening and a diagnostic procedure, explains Martin. So we ask if the patient is experiencing symptoms to determine whether this is really a diagnostic procedure. Because we tend to get referrals from the same primary care physicians, their staff members are starting to understand what we mean by high risk and screening.

Catherine Answered Fri 04th of November, 2011 01:52:55 AM

Very well answered. I often come across op notes that state screening and signs/symptoms. There are certain enteties that now refer to this as insidentals s/s. pt is scheduled for screening but when the nurse asks them before they enter the procedureroom, they would say "oh well I have some cramping and maybe constipation". I consider this still screening,because when the patient went to the GI doc, he had no complaints.

Linda Answered Thu 10th of November, 2011 19:23:41 PM

I am in desperate need of help. We are also in the process of learning the many, many guidelines to colonoscopies. To use the G0105 or G0121? or when to use 45378? We started off just using 45378 on everything until we found out we are suppose to be using colonoscopy screening codes especially for patients 50 + with history of polyps or family history of cancer. So now I have been coding anyone over 50 and under 75 with either a high risk G0105 or a low risk G0121. With mostly V code diagnosis. Someone just told me that unless it states screening colonoscopy of the report we should not code it with a G code even if the patient is Medicare and over 50. EX.#1 56 year old Patient comes in with stomach pain and change in bowel habits and turns out to have nothing wrong. I have been coding this as a G0121 with dx 789.00. or EX.#2 Report states, Patient is a 60 year old with history of colon polyps ( they rarely tell us what there last colonoscopy was) next to the history of colon polyps, they say screening being done to evaluate. I would use G0105 with V12.72. Please help. I recently sent out hundreds of G0105's and G0121's codes for 50 and older patients assuming anything is considered a screening and what about the G0121? No LCD for this.They are getting paid but is this correct? Like the woman above with get both signs and symptoms and screening colonoscopy indications, and 80% of these mention diverticulosis found, but I still use screening codes. We are an Ambulatory Coding and Billing Company. I pray I don't have to resubmit all these claims, this is all a learning experience.

Catherine Answered Sat 12th of November, 2011 12:59:45 PM

When I open an op note, the 1st thing I look for is age. Then indication. If it states regular screening, G-code comes to mind. G0121 for reg screen. G0105 for high risk or increased risks such as V10.05, V12.72, V16.0 and V18.5x. If there are any indications of 789.xx, 787.9X, 564.00 etc, and nothing is found, I consider these as insidental signs and symptoms and use the screening codes when also indicated. If only the insidental s/s are mentioned, I use 45378.

Now, if s/s such as 569.3, 578.1, 792.1, which are real indications of a problem, and screening is also listed as indication, I will not use G code. This is a diagnostic procedure billed with 45378 or depending whether physician finds polyp, and remove or bx it, 4538X. Sometimes patients come back stating it actually should have been a screening, I do not change these codes, since they had reLly a concrete problem. They bully you into doing this and this is considered fraud.

If your pt comes for a screening, regular or high risk, and bx or polypectomy is performed, you would still use the V code as primary dx and the polyp as 2nd, since this was the original intend. Append modifier Pt or 33 whatever is appropriate for the carrier you billed.

Lots of info and I typed it on my iPad, so pardon allthe typos.

Linda Answered Tue 15th of November, 2011 17:44:49 PM

I have one last question, first off, very grateful for all the info. I totally understand now. I just did a huge stack of colonoscopies and upper endoscopies. I noticed that many state, This is a Colon Screening and I understand you and Sanjit are stating if anything is found it is no longer a G code. But most of these have 1 hemorroid, or myochosis stage diverticula. Everyone has this. Myochosis stage is the beginning stage of diverticulosis, it is not a confirmed diagnosis, but what about the one and only small hemorrhoid found during a colon screening. This doesn't seem substantial enough to not use the G codes for cancer screening? almost everyone has these two things I am noticing in these reports. What do you think I should do?

Catherine Answered Wed 16th of November, 2011 03:01:32 AM

The finding like 562.10 or 455.x, is what we refer to as insidental. You can code and bill those, but as secondary dx, the intension was screening, and it should stay screening with G-code.

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