Oncology & Hematology Coding Alert

Question: Which family history and personal history ICD-9 codes prove medical necessity for Medicare's high-risk colorectal cancer screening?


Missouri Subscriber


Answer: When you report a high-risk colorectal cancer screening to Medicare (G0105, Colorectal cancer screening; colonoscopy on individual at high risk), your first step in proving medical necessity is strong diagnosis coding based on the patient's high-risk characteristics. 

Here are the personal and family history ICD-9 codes that indicate a patient may be at high risk for colorectal cancer:

Personal history

- V10.05---of malignant neoplasm; large intestine

- V10.06--- of malignant neoplasm; rectum,  rectosigmoid junction, and anus

- V12.72---of colonic polyps.
 
Family history

- V16.0---of malignant neoplasm; gastrointestinal tract

- V18.5---of digestive disorders (use for colon polyps)

- V19.8---of other condition (use for polyposis).

Tip: To qualify for Medicare's high-risk colorectal cancer screening benefit, the patient must typically meet requirements for diagnosis, age (at least 50 years old), and frequency (once every 24 months).