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General Surgery Coding Alert

Reader Question:

Diagnosis Matters for Screening Colonoscopy

Published on Wed Feb 25, 2004

Question: We recently filed a claim for a screening colonoscopy for a Medicare patient, but Medicare denied the claim. I thought Medicare was covering these screenings. Was I wrong?

Massachusetts Subscriber

Answer: Medicare will pay for a screening colonoscopy under certain well-defined circumstances:

  • For patients at average risk, Medicare will approve a screening colonoscopy once every 10 years for Medicare Part B beneficiaries over age 50 without signs or symptoms. The appropriate code for this service is HCPCS G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

  • For patients at high risk, Medicare will approve screenings every two years for Part B beneficiaries over age 50. For these screenings, you should report HCPCS G0105 (Colorectal cancer screening; colonoscopy on individual at high risk).

    In either case, your diagnosis must match with and justify the HCPCS procedure code. For G0121, approved ICD-9 codes include:

  • V16.0 -- Family history of colorectal cancer
  • V18.5 -- Family history of familial adenomatous polyposis
  • V12.72 -- Personal history of adenomatous polyps
  • V10.05, V10.06 -- Personal history of colorectal cancer.

    Additional approved codes for G0121 include inflammatory bowel disease, as well as Crohn's disease or ulcerative colitis (for example, 555.0, 555.1, 555.2, 555.9, 556.1, 556.2, 556.3, 556.8, 556.9, 558.2, 558.9).

    For patients at high risk (G0105), the most common approved diagnosis is V76.51 (Special screening for malignant neoplasms; intestine; colon).

    Medicare may not cover a screening endoscopy if the patient had a previous screening endoscopy and the frequency limits for that procedure have not passed. For instance, Medicare may not cover a screening colonoscopy for a patient at average risk (G0121) performed in March 2004 if the patient had a screening flexible sigmoidoscopy in March 2002. Four years must pass after a covered screening flexible sigmoidoscopy before the surgeon may be paid (by Medicare) for another covered screening scope. If the time frame has not passed, make sure the patient understands Medicare coverage rules and ask the patient to sign an advance beneficiary notice (ABN) waiver.

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