Wiki G0105 and Z86.010

[smbucy@yahoo.com]

In the past, all of the trainings and webinars said if a patient has personal history of polyps and no other diagnosis to bill G0105 and Z86.010. Recently, I attended a webinar and asked the presenter specifically. She told me to bill 45378 and Z86.010 to commercial payers. We have a lot of commercial payers that recognize the G0105 code and consider 45378 diagnostic. I haven't changed our process because I cannot find documentation either way.

Now, we are having issues with our facilities because our orders show 45378, so they are trying to collect on the patients the day of their procedure, stating that the physician ordered a diagnostic procedure. We have never used G0105 or G0121 on our orders. I'm not sure if this is just something that needs to be explained to the facility staff or if we really should be billing 45378 for personal history. Does anybody have any documentation one way or the other on this?

PS-I have looked at AMA, ASGE, AGA, HHS, etc., but I am not finding anything.

Thanks!

 

[mconner001]

Here in the state of Washington (western side) we add the Z12.11 as #1 dx as the Tip in the ICD-10 book says: "Surveillance colonoscopies are a type of screening exam used to screen for malignancies in those patients with history of polyps and/or cancer (previously removed)." Also, in the book the definition used right under the Z12 - is "Screening is the testing for disease or disease precursors in asymptomatic individuals so that early detection and treatment can be provided for those who test positive for the disease." We use the 45378 on non-Medicare claims along with the 33 modifier in those cases. For the Medicare plans we use the G0105 code with the Z86.010. Last I heard for this area is that Community Health Plan of WA (Medicaid plan) is the only other insurance that uses the G codes. We have not had an issue being paid. Hope that helps.

 

[kboyd22]

We are in Oklahoma and all of our carriers Medicare/Medicaid and Commercial plans recognize the G0121 for screening and G0105 for High risk screening; In order to use Z12.11 as the DX code, it must state that the procedure is a screening. If it states High Risk surveillance or High risk screening, it should indicate why it is high risk, such as personal hist of colon polyps or family history of colon cancer etc., then you would bill the G0105 and use the Personal/family history DX codes as the primary DX code. Now with the new colonoscopy LCD in place we are running into issues when a screening turns diagnostic/therapeutic because sometimes the DX for the diagnostic/therapeutic is not on the LCD and none of the Z codes are on the LCD for 45378, 45380 etc., even though we would be billing this with PT modifier.
Hope this helps.