General Surgery Coding Alert

As of July 1, 2001, Medicare will cover screening colonoscopies every 10 years for patients not at high risk for colorectal cancer. In a Feb. 8 transmittal (No. 1697, change request 1536), HCFA announced that section 4180.2-4180.9 of the Medicare Carriers Manual would be changed to indicate that HCPCS code G0121 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) should no longer be a noncovered service.

Note: Individuals who have had a covered flexible sigmoidoscopy (G0104) must wait four years before undergoing a screening colonoscopy.

Until now, Medicare only covered screening colonoscopies (once every 24 months) for beneficiaries at high risk for colorectal cancer. These screenings are coded G0105 (colorectal cancer screening; colonoscopy on individual at high risk).

To qualify as high risk, a patient must meet one or more of the following conditions:

A close relative (sibling, parent, or child) has had colorectal cancer or an adenomatous polyposis

A family history of familial adenomatous polyposis

A family history of hereditary nonpolyposis colorectal cancer

A personal history of adenomatous polyps, or a personal history of colorectal cancer

Inflammatory bowel disease, including Crohns disease, and ulcerative colitis.

An appropriate diagnosis code indicating one or more of the above conditions should be linked to G0105 on the HCFA claim form.

A single diagnosis code, V76.51 (special screening for malignant neoplasms; colon), is available for colonoscopies for patients at low risk. This V code must be linked to G0121 on the claim form, says Susan Callaway, CPC, CCS-P, an independent coding and reimbursement specialist and educator in North Augusta, S.C. If a sign or symptom such as abdominal pain is used, the screening colonoscopy claim will likely be denied, she notes.

If the screening detects a problem but no other procedure is performed, the diagnosis initially coded cannot be altered after the fact to reflect the new problem. For example, if the screening colonoscopy indicates that the patient has diverticulosis, only the screening diagnosis (V76.51) may be used. And, for some Medicare carriers, only the screening diagnosis and not the diverticulosis (562.10) diagnosis should be used even if the surgeon subsequently counsels the patient on healthier eating habits and lifestyles.

Other Medicare carriers have stated in their bulletins that if the diverticulosis is more than incidental (i.e., significant) and some form of treatment (which would include dietary counseling, for instance) is provided, the colonoscopy becomes a diagnostic procedure and diverticulosis may be used as the supporting diagnosis.

All Medicare carriers agree, however, that if during the course of the screening colonoscopy a lesion or growth is detected that results in a biopsy or removal of the growth, the appropriate code for the therapeutic procedure (for example, 45380, colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) should be billed, rather than G0121. In such a case, the appropriate diagnosis that best reflects the nature of the lesion should be linked to the correct CPT code.

Note: G0121 and G0105 are paid at the same rate as 45378 (colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]). According to the HCFA fee schedule, the 2001 facility rate is 9.95 relative value units (6.26 nonfacility).

Obtain a Waiver

Even after July 1 there will be several situations in which screening colonoscopies will still not be covered, and surgeons should require patients to sign an advance beneficiary notice (ABN) prior to administering the service. By signing this document, the patient indicates that he or she is aware that the service may not be covered and that he or she would therefore have to pay for it.

A surgeon seeing a new patient, for example, may be unaware that the patient had a flexible sigmoidoscopy at another physicians office fewer than four years ago. If the ABN is not signed and modifier -GA (waiver of liability statement on file) is not appended to G0121 the surgeon will not be able to bill the patient after the explanation of benefits (EOB) returns and the claim is denied.

HCFA Releases Draft of Simple Advance Beneficiary Notice HCFA has released a draft version of a new advance beneficiary notice (ABN) form designed to be more readable and easier to understand. Simplifying the ABN was among the top-five priority issues recently identified by doctors for HCFA to address. ABNs are used by physicians and medical-equipment suppliers to notify Medicare patients that Medicare probably will not pay for a service or item. If the patient still wants the service, an ABN must be signed to indicate the patient is aware that he or she will have to bear the cost. The revised ABN specifies: Medicare does not pay for all of your health care costs. Medicare only pays for covered items and services when Medicare rules are met. The fact that Medicare may not pay for a particular item or service does not mean that you should not receive it. There may be a good reason your doctor recommended it. Right now, in your case, Medicare probably will not pay for the item or service. The ABN also advises the beneficiary to ask for a further explanation if he or she is unsure why Medicare probably will not pay, and to check how much the item or service will cost either out-of-pocket or through other insurance. The patient is then asked to check one of two options, and sign and date the form. The first option reads, Yes, I want to receive these items or services. The second option reads, No, I have decided not to receive these items or services. Note: The draft, single-page ABN can be downloaded for viewing at www.hcfa.gov/regs/prdact95.htm. Click the link just below the heading April 19, 2001 Information Collection Requirements in HCFA-R-131.

E/M With Screen Probably Not Covered

The ABN also applies to any E/M services performed with G0121 because such services are far less likely to be paid by carriers than the screening colonoscopy itself.

If you know the E/M service will be denied, you can bill the patient up front, Callaway says. But in most cases, you must bill the patient after the denial comes back from the carrier. Therefore, you need to get a waiver for the E/M also.

Note: Modifier -GA should also be attached to the E/M service.

In some cases, the surgeon may perform the colonoscopy with minimal workup, into which any E/M services are bundled. In other cases, however, the surgeon may perform a complete workup days before the colonoscopy is scheduled.

If the E/M consists only of a preoperative evaluation, its bundled with the screening colonoscopy, says Kathy Pride, CPC, CCS-P, coding supervisor with Martin Memorial Medical Group in Stuart, Fla. But the preoperative included in the global period of any procedure is typically a brief, last-minute check not a full evaluation. If a full workup is performed, it is significant and separately identifiable, and the surgeon should be paid for it. She notes that a surgeon is unlikely to administer conscious sedation to a patient with a screening colonoscopy without performing such an exam.

Even when a full workup is performed obtaining payment could be difficult because the service has been performed with a screening colonoscopy. Nevertheless, an E/M code should be submitted to the carrier if only to obtain a denial so the patient can be billed for the service.

Depending on the carrier, the E/M service may be billed either as a low-level new- or established-patient visit (with screening colonoscopy as the chief complaint), as a preventive service (codes 99381 through 99397) or as an unlisted E/M service (99499). In all three cases, the screening V code (V76.51) should be linked to the E/M service as well as to G0121.

As with the screening colonoscopy, the Medicare carrier will send the surgeon an EOB stating that the E/M is a noncovered service and that the patient is responsible for the full fee. The patient is sent a letter to the same effect.

The ABN used for the colonoscopy may also be presented to the patient for any E/M services provided, Callaway says.