Internal Medicine Coding Alert

Published on Mon May 26, 2008 PDF

Question: We've scheduled a 68-year-old Medicare patient for an average-risk colonoscopy screening. He has never had a Medicare-covered colonoscopy before, but his record indicates that Medicare has paid his bill for a flexible sigmoidoscopy screening. Is this patient entitled to a covered colonoscopy screening?

Indiana Subscriber

Answer: It depends on how long ago the patient had the sigmoidoscopy. Medicare allows covered screening colonoscopies once every 10 years for patients who are at average risk of colorectal cancer and at least 50 years old.

However, if the patient had a Medicare-covered flexible sigmoidoscopy screening within the last 48 months (G0104, Colorectal cancer screening; flexible sigmoidoscopy), then the patient is not eligible for the covered colonoscopy (G0121, Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).

Best practice: You should find out the exact date of the patient's flexible sigmoidoscopy; if the screening occurred more than 48 months ago, the patient is entitled to the covered colonoscopy.

But if the patient's sigmoidoscopy was fewer than 48 months ago, let him know that Medicare will likely deny the claim. If he still wants the service, have him to sign an advance beneficiary notice (ABN) explaining that Medicare may deny the service due to frequency rules.

If you go this route, be sure to append modifier GA (Waiver of liability statement on file) to G0121 to show Medicare that you have explained the coverage situation to the patient.

Benefit: If Medicare doesn't pay for part or all of the service, and you have an ABN on file, you can bill the patient for the outstanding balance.