G0121 Will Be Reimbursed For Average-risk Screening Colonoscopies
Published on Tue May 01, 2001
Effective July 1, 2001, HCFA will extend the benefit of a screening colonoscopy to Medicare patients not at high risk (also known as average risk) for developing colorectal cancer. In a transmittal dated Feb. 8, 2001, the agency stated that HCPCS code G0121 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) should be used to report the new benefit, and that the payment for all screening colonoscopies should be the same as the payment for a diagnostic colonoscopy (45378).
The policy is good medical care and is in keeping with the results of studies showing the effectiveness of colonoscopy in decreasing colorectal cancer death and colonoscopys superiority over all other screening tests, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT Advisory Panel. During the past few years it was difficult to explain to a patient that the screening colonoscopy advised by his or her primary care physician was not covered by Medicare. The complete colorectal cancer screening policy that is effective July 1, 2001, (with changes in boldface) is as follows:
Screening fecal-occult blood tests (G0107) for beneficiaries who have attained age 50, and at a frequency of once every 12 months.
Screening flexible sigmoidoscopies (G0104) for beneficiaries who have attained age 50 at a frequency of once every 48 months.
Screening colonoscopies (G0105) for beneficiaries at high risk for developing colorectal cancer at a frequency of once every 24 months.
Screening colonoscopies (G0121) for beneficiaries not meeting the criteria of high risk at a frequency of once every 10 years. (Note: Prior to July 1, 2001, this code is used to report noncovered screening colonoscopies on Medicare beneficiaries who did not meet the criteria of high risk.)
Screening barium enema examinations (G0106 and G0120) are covered as an alternative to either a screening sigmoidoscopy (G0104) or a screening colonoscopy (G0105). Note: If its a substitute for a G0104, use the G0104 frequency parameter of once every 48 months. If its a substitute for a G0105, use the frequency parameter of once every 24 months.
Problems with High-risk Criteria
Ever since the original colorectal cancer screening policy was established as part of the Balanced Budget Act of 1997, gastroenterologists have disliked the screening colonoscopy benefit. One of the problems was defining who was high risk. HCFAs national policy states that the following diagnosis codes meet the high-risk criteria:
V10.05 personal history of malignant neoplasm of large intestine
V10.06 personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus
555.0 regional enteritis of small intestine
555.1 regional enteritis of large intestine
555.2 regional enteritis of small intestine with large intestine
555.9 regional enteritis of [...]
