Wiki High Risk Surveillance Colonoscopy at one year interval

[codegirl0422]

Hello, is there ever a chance that Medicare will pay for a high risk colonoscopy at a one year interval? Some utilization management guidelines for Health Plans and latest society literature state that colonoscopy can be repeated in one year if an advanced adenoma is found. But I do not see anything in the CMS manual, NCD or LCD stating such.

 

[xXxPARAGONxXx]

Hello, is there ever a chance that Medicare will pay for a high risk colonoscopy at a one year interval? Some utilization management guidelines for Health Plans and latest society literature state that colonoscopy can be repeated in one year if an advanced adenoma is found. But I do not see anything in the CMS manual, NCD or LCD stating such.

Medicare will pay for it, but not entirely. Medicare will pay 80%, and the patient will be responsible for 20%. You will need to complete and have the patient sign an ABN, informing the patient that they will likely be responsible for 20% of the cost.

Medicare only pays at 100% for a high-risk screening colonoscopy (G0105) every two years.

 

[codegirl0422]

Medicare will pay for it, but not entirely. Medicare will pay 80%, and the patient will be responsible for 20%. You will need to complete and have the patient sign an ABN, informing the patient that they will likely be responsible for 20% of the cost.

Medicare only pays at 100% for a high-risk screening colonoscopy (G0105) every two years.

Thank you. So they will pay part of it? (the 80%) even though CMS manual states every two years for screening?

 

[xXxPARAGONxXx]

Thank you. So they will pay part of it? (the 80%) even though CMS manual states every two years for screening?

I would request preauthorization for a diagnostic colonoscopy and also bill it as a diagnostic colonoscopy, knowing that Medicare will not cover it as a screening colonoscopy (because if it did, Medicare would pay at 100%).

 

[TamGIGal]

In my experiences, Medicare will cover as diagnostic. Don't code it as a screening, otherwise it will be denied. If provider performed bx, code what is found, without a screening modifier. If nothing is found, code it as 45378 and dx Z09, Z86.010. I hope this helps.