Use G Code for Reporting Average-risk Colon Screening
Published on Thu Feb 01, 2001
Due to recent publicity campaigns about the effectiveness of preventive screenings for colorectal cancer, more patients are going to gastroenterologists and requesting a screening colonoscopy. For many of these patients, the screening colonoscopy will not be covered by Medicare because they do not exhibit any signs or symptoms that would qualify them for a diagnostic colonoscopy (45378) or a personal/family history of colon cancer that would qualify them for a high-risk screening colonoscopy (HCPCS code G0105 for Medicare patients). In addition, many commercial insurers do not have a screening benefit for high- or average-risk patients. Gastroenterologists are beginning to question how they should best handle the special billing and coding dilemmas posed by these average-risk screening colonoscopies.
Assessing Colorectal Screenings
According to the Medicare Carriers Manual (MCM) section 4180.1, Medicares coverage of colorectal screening tests for asymptomatic patients includes the following procedures:
Screening fecal-occult blood tests are covered at a frequency of once every 12 months for beneficiaries who have attained age 50;
Screening flexible sigmoidoscopies are covered at a frequency of once every 48 months for beneficiaries who have attained age 50;
Screening colonoscopies are covered at a frequency of once every 24 months for beneficiaries at high risk for colorectal cancer. While the specific diagnosis codes covered for a high-risk screening colonoscopy vary from carrier to carrier, individuals with a family or personal history of colorectal cancer or who have inflammatory bowel disease are generally considered to be at high risk; and
Screening barium enema examinations are covered as an alternative to either a screening sigmoidoscopy or screening colonoscopy examination. The same frequency parameters specified in the screening sigmoidoscopies or colonoscopies apply.
Average-risk Screenings Are Not Paid by Medicare
Recent literature [in the New England Journal of Medicine] has shown that colonoscopy is effective in decreasing mortality from colon cancer. Flexible sigmoidoscopy [a benefit to average-risk Medicare patients] is also effective but misses growths in the right colon, explains Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and a former member of the CPT advisory panel. There are some individuals in the public eye, such as Today show host Katie Couric, who advocate average-risk screening colonoscopies beginning at age 40.
Although there is a HCPCS code (G0121, colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for reporting average-risk screening colonoscopies, this is not a benefit covered by Medicare or most commercial insurers, which means the patient usually must pay. Patients presenting with a request to have an average-risk screening colonoscopy must be made aware of insurance coverage consequences, Weinstein says. Ultimately, the patient must decide if the expense is worth the added screening thoroughness and piece of mind.
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