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Internal Medicine Coding Alert

READER QUESTIONS:

Screen Your ICD-9 Colonoscopy Codes

Published on Sun Feb 27, 2005 Print Friendly and PDF PDF

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?


Florida 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 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 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 G0105, 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 G0105 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 and 558.9).

    For patients at high risk (G0121), 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 2005 if the patient had a screening flexible sigmoidoscopy in March 2003. 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 him to sign an advance beneficiary notice waiver.

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