Wiki G0105 VS 45378 HELP

[kitazamora]

I am new to GI coding pt is having a colonoscopy

Indications: Personal Hx of Malignant Rectal Neoplasm s/p LAR, hx of elevated CEA. Pt last surveillance was in 2021 with adenomas and recommended recall was 3 years.

Pt recently had elevated CEA levels which is why our doctor ordered procedure to be done before the 3 years.

Findings: Entire colon was normal, patent end to end Colo-rectal anastamosis with healthy mucosa
no specimens collected. Insurance is Medicare.

I know medicare pays for a G0105 every 2 years. Could I use G0105 in this case being that it has been just over 2 years and she has a hx of malignant neoplasm? or would it be better to bill 45378
any advice is helpful! thank you!

 

[CBLENNIE]

I think the answer to your question is going to depend on who your payer is. I'm guessing you aren't asking about Medicare because you know they want G0105, for Medicaid and commercial insurance companies that you are contracted with, you should be looking for their policies to see if they will accept G0105 or if they want 45378. Sorry I don't have a definitive answer for you, but this is the best advice I can give without more information on who you are submitting your claim(s) to.

 

[thomas7331]

I would use G0105 since there is no mention of any new symptoms or problems identified since the last colonoscopy that would make it a diagnostic procedure.

 

[kitazamora]

I think the answer to your question is going to depend on who your payer is. I'm guessing you aren't asking about Medicare because you know they want G0105, for Medicaid and commercial insurance companies that you are contracted with, you should be looking for their policies to see if they will accept G0105 or if they want 45378. Sorry I don't have a definitive answer for you, but this is the best advice I can give without more information on who you are submitting your claim(s) to.

Thank you! I did indicate in my message that the insurance was Medicare. I will try my hand with the G0105

 

[CBLENNIE]

Thank you! I did indicate in my message that the insurance was Medicare. I will try my hand with the G0105

My apologies, I missed where you indicated the payer is Medicare. That said, the advice to use G0105 given by other posters is correct IMO.