Gastroenterology Coding Alert

 Medicare will deny high-risk screenings if you don't meet guidelines No gastroenterology office wants to deny a Medicare patient his rightful high-risk colonoscopy screening. But if you don't satisfy three important rules on your claim, your office may end up footing the bill.
 
Truth: To qualify for Medicare's high-risk colorectal cancer screening benefit, the patient must meet diagnosis, age and frequency requirements, says Linda Parks, MA, CPC, CMC, CCP, CMSCS, an independent coding consultant in Marietta, Ga. Failure to meet any one of these marks means that the patient is not eligible for the G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) screening - and Medicare will likely deny the claim.
 
For advice on filing a top-notch G0105 claim, we consulted experts on how to satisfy Medicare requirements. Read on for input on acing Medicare's high-risk rules regarding diagnosis, age and frequency. Identify High-Risk Characteristics Via ICD-9 You can identify high-risk patients through their family histories or the symptoms they have displayed individually. According to Parks, Medicare considers an individual potentially at high risk for colorectal cancer if the patient has:
   a close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp
   a family history of familial adenomatous polyposis
   a family history of hereditary nonpolyposis colorectal cancer
   a personal history of adenomatous polyps
   a personal history of colorectal cancer
   inflammatory bowel disease
   Crohn's disease
   ulcerative colitis. Example: Suppose a Medicare patient with a history of regional enteritis reports for a high-risk screening. On the claim, you must reflect the patient's high-risk characteristics by attaching 555.9 (Regional enteritis; unspecified site) to G0105 to represent the patient's enteritis.
 
(For a more comprehensive list of ICD-9 codes that signify high-risk characteristics in Medicare patients, see "You Be the Coder: Dx Codes and High-Risk Patients" on page 43.) V Codes Are Often Necessary Many G0105 claims will include a V code, though there are a couple of exceptions. If a patient has a chronic digestive disease that your Medicare carrier covers, then a V code may not be necessary - though you should still include an appropriate ICD-9 code, Parks says.
 
Check with your local Medicare payer for a list of chronic diseases that do not require a V code for a G0105 encounter.  Patient Must Be Old Enough for G0105 Even if a patient has the characteristics of an individual at high risk for colorectal cancer, most Medicare carriers will not cover a G0105 screening unless the patient is at least 50 years old, Parks says.
 
However, there may be some local Medicare carriers that don't have age requirements written into their policies. For example, "Part B-Texas Trailblazer Health does not indicate an age requirement for a Medicare recipient to [...]