Gastroenterology Coding Alert

Question: We had a Medicare patient come in for a colorectal cancer screening. What constitutes a high-risk patient?

Wyoming Subscriber

Answer: According to the Medicare Claims Processing Manual, the agency considers a patient who is at high risk of developing colorectal cancer as an individual who has at least one of the following characteristics:

• Close relative, such as a sibling, parent, or child, who had an adenomatous polyp or colorectal cancer;
• Family history of familial adenomatous polyposis;
• Family history of hereditary nonpolyposis colorectal cancer;
• Personal history of colorectal cancer or adenomatous polyps; or
• Inflammatory bowel disease (IBD), such as Crohn’s disease, and ulcerative colitis.

If a gastroenterologist performs a colorectal cancer screening on a Medicare patient who meets any of the criteria above, you’ll assign G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) to report the procedure. On the other hand, you’ll assign G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) when the patient doesn’t fit the high-risk patient criteria.

Frequency: Screening colonoscopies may be reimbursed when a provider performs the procedure after a certain timeframe depending on the individual. High-risk Medicare beneficiaries may receive a screening colonoscopy (G0105) once every 24 months. Meanwhile, Medicare patients who are not at a high risk of colorectal cancer may receive a screening colonoscopy (G0121) once every 10 years.

Mike Shaughnessy, BA, CPC, Development Editor, AAPC