Answers to Your Questions on Screening Colonoscopies
Published on Tue Jan 01, 2002
Due to recent publicity campaigns touting the benefits of colorectal cancer screenings and a new screening benefit for average-risk patients, more Medicare beneficiaries have been seeking screening colonoscopies from gastroenterologists. Because Medicare carriers have been slow to release updated guidelines for these benefits, the increase in demand for screenings has also brought an increase in questions, such as how to bill for an E/M service prior to the screening or the proper way to report a discontinued procedure.
Medicare's national policy for screening colonoscopies includes the following:
Screening colonoscopies (G0105) for beneficiaries at high risk for developing colorectal cancer one every 24 months. Although the criteria for those who are considered to be at high risk varies from carrier to carrier, most carriers will cover those individuals who have a personal history of colon cancer (V10.05) or cancer of the rectum (V10.06). They also cover individuals with Crohn's disease (555.0-555.9) or ulcerative colitis (556.0-556.9). Some carriers may also cover individuals with a personal history of colonic polyps (V12.72), family history of colorectal cancer (V16.0) or a family history of digestive disorders (such as colonic polyps) (V18.5).
Screening colonoscopies (G0121) for beneficiaries not meeting the criteria of high-risk one every 10 years. Note: Prior to July 1, 2001, this code was used to report non-covered screening colonoscopies on Medicare beneficiaries who did not meet the criteria of high-risk. The national policy does not list a diagnosis code that should be used when reporting the average-risk screening but most carriers accept V76.51 (special screening for malignant neoplasms; colon).
E/M Service Usually Not Billable
Probably the most common question that is asked with regard to both types of screenings is whether Medicare will reimburse for an E/M service performed in conjunction with the screening. The general consensus among coding experts is that Medicare will not reimburse for an E/M service that deals only with the screening about to be performed. Some gastroenterology medical societies have been lobbying CMS for a change in this policy.
"Our gastroenterologists always perform a history and physical before each screening," says Carol Pohlig, CPC, BSN, RN, a reimbursement analyst for the Hospital of the University of Pennsylvania Department of Medicine. "But that's just part of the procedure, part of the global package, even if it's only a one-day package."
Some practices report that they do not do a full-blown E/M in an "open-access" situation where the patient's primary care physician arranges for the screening. Instead, a nurse may speak to the patient over the phone prior to the colonoscopy or the gastroenterologist may review the primary care physician's records in advance.
In cases where the patient needs to see the gastroenterologist prior to the screening because no [...]
