NEED FAST HELP re; G0105

poxleitner

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Hi all,
I'm hoping to get some fast help on this topic as we run into this scenario all the time at our facility and us in coding keep butting heads about the right way to go about it.
There does not seem to be clear documentation out there as to when a patient is considered "high risk" allowing us to append G0105 rather than a G0121.
Here is the scenario that we are having trouble with.

MCR patient in for a first screening colonoscopy, no signs, symptoms or family history, during the "screening colonoscopy" Dr finds diverticulitis, does not do any biopsies.

So, I have an intended screening colonoscopy that one coder feels would be just a G0121 with V76.51
And another coders opinion that the patient qualifys for being "high risk" G0105 as the diverticulitis code was found and is listed under the LCD as being covered for the G0105.

I guess my main question is, who what when and why determines that a patient is meeting criteria for "high risk"
IMO I feel that the finding should drive the cpt code to G0105, allowing the patient to be covered every 2 years from here on out.
Another opinion is coding G0121 now and then doing "high risk" G0105 the next time.

To me that is like coding a cough when the patient has bronchitis, you should be coding the most definitive diagnosis known at the time, in this case the diagnosis can drive your CPT code to be different, so what's the right way to go?

There are quite a few diagnosis listed under the G0105 including diarrhea, when is diarrhea supposed to be considered "high risk" or a sign or symptom for indicated procedure.
Thanks in advance for your help!!!!
Ang
 

grossap

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According to the documentation I've read, the CPT would change from G code to 45378 and a PT modifier. The dx codes would be V76.51 w/ second dx of (diverticulitis)
 

poxleitner

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I don't forsee there ever being a reason you would use code 45378-PT on a medicare patient, from what I've read it is geared for a biopsy and above....45380-45385 codes.
 
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