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History of Polyps Colonoscopy for Medicare

SUEV

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Local Chapter Officer
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From my understanding, Medicare only considers a history of polyps (V12.72) high risk if the polyps were adenomatous. Many times my provider doesn't know whether they were or not. When he doesn't know and the diag is V12.72, I don't use the G0105 for screenings since I don't have documentation to prove that they were at high risk. Does anyone handle these situations differently?
Thanks,
Sue
 

MelissaCCS-P

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Anytime we see patients that have personal or family history of CA or any type of polyps, we use the G0105. The majority of the time this is the case.
 

SUEV

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Supporting Medical Necessity

That is what I normally use since I can't prove the history of polyps were adenomatous. Also, Medicare is very specific about the types of family hsitory that it considers high risk. Here's what's listed in the CMS preventive guide:

An individual considered to be at high risk for developing colorectal cancer has one or more of the following risk factors:
 A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp
 A family history of familial adenomatous polyposis
 A family history of hereditary nonpolyposis colorectal cancer
 A personal history of adenomatous polyps
 A personal history of colorectal cancer
 A personal history of inflammatory bowel disease, including Crohn's Disease and ulcerative colitis

So, if a pt has V12.72 or V16.0 as a diag but the provider doesn't know if the polyp was adenomatous or that the family history (non-close relative) was specifically hereditary nonpolyposis colorectal cancer, would it be fraudulent to bill a high risk colorectal screening when we can't prove we meet Medicare's criteria for high risk? I've seen articles that say since h/o polyps & adenomatous polyps code to the same thing (V12.72) that it doesn't matter but it seems to me that Medicare would make that distinction for a reason. Since colonoscopies are on the OIG work list for 2009 I want to make sure I understand when to bill a high risk screening and when it's inappropriate. I also don't want to lose money by being too cautious. Am I making a mountain out of a mole hill??
 

elenax

Expert
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Stuart
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This is from the Gastroenterology Coding Alert 2009..."How you know": Cite V codes when reporting high risk screening colonoscopies (G0105). Some diagnoses that justify Medicare screening colonoscopies includes besides V12.72 and V16.0: V10.05, V12.79("other diseases of digestive system") AND V18.5...("other specific conditions;digestive disorders") not only 'adenomatous polyps'...can also determine how you code a screening colonoscopy and depending on the patient's age could determine eligibility.

hope this helps!!
 

coderguy1939

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I'm jumping into this one a little late, but do all carriers use the same guidelines to determine who is considered a close relative? Would a grandparent with a HX of colon cancer qualify as a close relative for non-Medicare patients?
 
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