Wiki Colonoscopy for High Risk patient

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cbutsko

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Good morning,

I need to know if there are any circumstances under which Medicare covers a colonoscopy for surveillance purposes more often than every 2 years? We have a patient who had been diagnosed with colon cancer 2 years ago, had a colon resection, had a surveillance colonoscopy in Sept, 2015, and was then sent to us by her oncologist for another surveillance scope in January, 2017. I coded the January scope with diagnosis codes Z12.11 and Z85.038. Medicare denied it due to frequency stating she was not eligible for another one until Sept, 2017.

I'm thinking our only avenue of payment would have been to have the patient sign an ABN and bill them for it when Medicare denies. I need to be sure that is correct.

Thank you in advance for any insight you can offer,

Cate
 
Thanks so much for the link. My apologies for not getting back to you sooner. I was having difficulty with the website and my credentials. I've read through it, and it was very informative. However, none of those scenarios apply. Our medicare patient has had scopes closer than 2 years apart (just a few months apart). I suspect that Medicare will not reimburse for them more frequently than every two years for a high risk patient, but I need to confirm that for our physicians.

Thanks again,

Cate
 
In this instance a diagnostic scope will be covered but a screening/surveillance will not. High risk only gets every 2 years, no exceptions.
 
It sounds like the colonoscopy is for Z85.038. Therefore, I would code 45378-Z85.038 because that is stating it is for surveillence purposes. If you were doing a screening, which is every 2 years, then you would code G0105-Z85.038. Z12.11 is for average risk screening (G0121) once every 10 years. Try looking up your LCD's for 45378 as well. My locality LCD's state Z85.038 as a covered diagnosis with 45378. You shouldn't have any frequency limitations using 45378. It's the G0105 and G0121 codes that start the clock. Hope this helps!
 
Thank you!

I do appreciate the feedback. I suspected I was correct but wanted a "second opinion" to pass on to my physicians.

Have a great day!
 
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