Primary Care Coding Alert

Medicare has frequency requirements for average- and high-risk patients

Medicare patients who present to your FP for a colorectal cancer screening colonoscopy can present coding confusion if you don't know all the screening policy basics.

The patients must meet age and frequency requirements to have an average-risk Medicare-approved screening--and the guidelines only get more stringent when you-re coding for a high-risk screening.

Danger: Coders who don't know these requirements risk miscoding one of their screening claims. And if your FP provides a colorectal cancer screening to a Medicare patient who does not meet screening parameters, the practice will have to cover the screening itself. 10-Year Rule Applies to Average-Risk Patients Medicare allows patients who are at average risk for colorectal cancer to receive covered screening colonoscopies once every 10 years, says Carol Pohlig, RN, CPC, ACS, a senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia.

Example: A 60-year-old average-risk patient reports for a colonoscopy screening to check for colorectal cancer on March 2, 2007. The family practitioner provides the screening and sends the patient home. On the claim, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) for the screening.

Unless this patient's risk category changes, he is not entitled to another covered screening until March 2017.

Caveat: If your patient has had a Medicare-covered cancer screening via flexible sigmoidoscopy (G0104, Colorectal cancer screening; flexible sigmoidoscopy) within the last 48 months, he is not eligible for a colonoscopy screening, says Cynthia Swanson, RN, CPC, senior managing consultant for Seim, Johnson, Sestak & Quist LLP, in Omaha, Neb.

According to Medicare, average-risk patients who have had covered flexible sigmoidoscopy screenings must wait four years before having a covered colonoscopy screening, Swanson says.

So if a 54-year-old average-risk Medicare patient had a flexible sigmoidoscopy screening on May 5, 2004, he would not be eligible for a covered screening colonoscopy until at least May 2008. Check Carrier Dx Requirements for G0121 In general, you should use G0121 with diagnosis code V76.51 (Special screening for malignant neoplasms; intestine; colon). But some payers may allow other diagnosis codes for G0121 in their regions.

Best bet: If you don't know the payer's policy on G0121, check its local coverage determination for more information, Swanson says. High-Risk Screenings Require ICD-9 Proof When your practice performs a colonoscopy screening on a Medicare patient at high risk for colorectal cancer, you-ll code the encounter with G0105 (Colorectal cancer screening; colonoscopy on individual at high risk). Patients at high risk are entitled to a covered screening once every two years, Pohlig says.

Some payers might set a minimum age of 50 for covered high-risk screenings, even though Medicare has no
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