Question: Which diagnosis code should we use when reporting HCPCS code G0121? Also, can you tell us if G0121 has been added to CMS approved procedure list for ambulatory surgery centers (ASCs)?
Pennsylvania Subscriber
Answer: When CMS established the new policy effective July 1, 2001, that extends the benefit of a screening colonoscopy to Medicare patients not at high risk for colorectal cancer (also known as average risk), the agency did not specify any covered diagnosis codes for reporting the service.
Based on basic ICD-9 coding rules, V76.51 (screening for malignant neoplasms; colon) seems to be the most appropriate code, says Kathy Pride, CPC, coding supervisor for Martin Memorial Medical Group, a multispecialty practice with two gastroenterologists in Stuart, Fla. While Prides practice has only recently started billing for the average-risk screening colonoscopies and hasnt found out yet whether that diagnosis will be paid, she doesnt anticipate any problems with using that V code.
The new Medicare benefit provides screening colonoscopies for patients who do not meet the criteria of high risk at a frequency of once every 10 years. Prior to July 1, 2001, G0121 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) was used to report noncovered screening colonoscopies performed on Medicare beneficiaries who did not meet the high-risk criteria. In addition, those patients who would otherwise qualify to have a covered G0121 screening colonoscopy performed but have had a screening flexible sigmoidoscopy (G0104) must wait at least 48 months following the flexible sigmoidoscopy before they can receive a screening colonoscopy.
Because carriers have the authority to specify their own particular diagnosis code, Pride also recommends that gastroenterologists keep an eye on their carriers local Medicare bulletin for announcements about the new G0121 benefit.
Regarding your question on ASC reimbursement for the procedure, G0121 has been added to CMS list of approved procedures and has been classified as a Payment Group 2. However, gastroenterology practices may face delays in receiving facility fees for this procedure because Medicare payers may not have the new ASC fee in their computer systems yet. According to Transmittal #AB-01-81, CMS will allow payers to hold up the processing of G0121 claims until updated ASC facility rates are installed in their computer systems. Interest will be paid on clean ASC claims delayed beyond the statutory claims-processing timeliness standards.
For more information on the coding and reimbursement for G0121, please see G0121 Will Be Reimbursed for Average-Risk Screening Colonoscopies on page 33 of the May 2001 Gastroenterology Coding Alert. Additional copies can be requested via our Web site at
www.codinginstitute.com or by calling 1-800-508-2582.
