Wiki Need diagnosis other than Z12.11 for colonoscopy screening for transplant patient

[patdow]

I’m looking for advice on how to bill a colonoscopy screening for a patient who is high risk due to her transplant status. She has Medicare and needs colonoscopies every 5 years due to her transplant status. She has had no findings in her previous colonoscopies. She also has no family history of colon cancer. Additionally, she has no abdominal/GI related diagnosis that I can use.

I used Z12.11 as only diagnosis and G0121 for her CPT code and Medicare denied.

 

[thomas7331]

Transplant status is not one of the criteria that Medicare recognizes as qualifying a patient as high risk, so I believe that this service is going to be statutorily excluded from coverage if performed at the 5-year interval recommended for a high risk patient. I'm not sure that there's anything you can do to get this paid as it's written into the Medicare law this way. If the patient did have one of the qualifying criteria to meet Medicare's definition of a high risk patient, it would be billed with G0105 instead of G0121.