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High Risk Colonoscopy

  1. #1
    Default High Risk Colonoscopy
    Medical Coding Books
    Please help. Is anyone else seeing denials for medical neccesity from Medicare when billing G0105 with dx V12.72? this just started for us in July and am getting no good direction with Medicare.

  2. #2
    Dover Seacoast New Hampshire
    We code the screening code primary (V76.51), with the V12.72 secondarily. It's still a screening, just the same.
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

  3. #3
    We received a denial for the same reason today. Where is your practice, we are in NC. Palmetto referred us to the NCD, however, they stated that the NCD has not been updated on the CMS website, but that it was effective 7/1/14. I am still researching, there is absolutely nothing on the CMS website. I am wondering if they are going to move hx of colon polyps and family hx to the low risk category.

    Colorectal Cancer Screening Tests
    NCD 210.3
    IOM Publication 100-03 Medicare National Coverage Determinations, Chapter 1, Section 210.3
    NCD Original Effective Date: 01/01/2004
    CPT/HCPCS Codes
    CPT Code Description
    G0105 Colorectal cancer screening; colonoscopy on individual at high risk
    G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema

    ICD-9 Code(s) that Support Medical Necessity
    Use of these codes does not guarantee reimbursement. The patient's medical record must document that the coverage criteria in this NCD have been met.

    Partial List of ICD-9-CM Codes Indicating High Risk: Only applicable to G0105 and G0120 (high risk colorectal screening)

    Code Description
    555.0 Regional enteritis of small intestine
    555.1 Regional enteritis of large intestine
    555.2 Regional enteritis of small intestine with large intestine
    555.9 Regional enteritis of unspecified site
    556.0 Ulcerative (chronic) enterocolitis
    556.1 Ulcerative (chronic) ileocolitis
    556.2 Ulcerative (chronic) proctitis
    556.3 Ulcerative (chronic) proctosigmoiditis
    556.8 Other ulcerative colitis
    556.9 Ulcerative colitis, unspecified
    558.2 Toxic gastroenteritis and colitis
    558.9 Other and unspecified noninfectious gastroenteritis and colitis
    V10.05 Personal history of malignant neoplasm of large intestine
    V10.06 Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus

  4. #4
    cpoeward thanks for tour reply. We are in SC, so we are in the same jurisdiction. I was beginning to think we were the only ones having this issue. I sent you a private message on here discussing steps i have taken to try to get resolution. Please keep me updated with your progress as i will you also.


  5. #5
    Charlotte, NC
    Default ugh
    I'm in NC too and having the same luck as everyone else finding anything about this new policy from 7/1/14 except for what Palmetto has. Can't find a thing about it and I've been researching online for 3 days here and there. Nothing in any MLN Matters about this change, nothing on the CMS.gov website.

    The AGA has not put out anything either.

    Very frustrating.

  6. #6
    I have found a MLN #8691 that references this NCD that became efffective 7/1/14. THis has to be related, but my understanding of the memo is that the changes were only to enable their system to accept icd-9 or icd-10 codes. It states that no POLICY changes were made. I think this is a Medicare System issue, but cant get anyone at medicare to see that... I have emailed the Medical Director but have not received a response. I have also exculated one of our claims to a manager. We have appealed one claim. But this is much bigger than a claims denial issue. Please let me know if you have any updates and i will you as well.

  7. #7
    This is a posting that was in ASCA Connect the by boss forwarded to me. We haven't run into this issue... yet... at our facility. but it seems that a lot of people are having issues.

    Subject: RE: Palmetto GBA Denying G0105 with V12.72

    Thanks, Beth! That's what we started doing, but we never had to before. These cases are considered surveillances not true screenings and according to the AAPC literature and the ASC Winter Coding conference you drop the V76.51. However, I do realize that we need to code according to payer protocol. I just think it odd that they just started rejecting after all this time...
    Dawn Langness CPC-H
    Outpatient Surgery Center of Hilton Head
    Hilton Head Island SC

    Original Message:
    Sent: 07-22-2014 09:25
    From: Beth Hamilton
    Subject: Palmetto GBA Denying G0105 with V12.72

    Have you tried coding V76.51 first, to indicate the screening, then V12.72 to indicate high risk?
    Beth Hamilton CPC CASCC
    Twin Cities Surgery Center
    Festus MO

    Original Message:
    Sent: 07-21-2014 10:54
    From: Dawn Langness
    Subject: Palmetto GBA Denying G0105 with V12.72

    Has anyone else been receiving denials for listing ICD9 V12.72, History of Polyps for a high risk screening? Two calls to Palmetto GBA has received the same response that NCD 210.3 was just updated and that the V12.72 is no longer acceptable to code with G0105. I searched and can't find any such update. Also, since G0105 is listed on the ASC-10 Quality Report for diagnosis V12.72, V13.89, and V10.05 I would think that CMS would have sent an update for that reporting, too.


    Dawn Langness CPC-H
    Outpatient Surgery Center of Hilton Head
    Hilton Head Island SC

    Jennifer DeWitte, CPC, CPC-P, CPB, AAPC Fellow
    Newport Center Surgical
    Coding & Billing Department
    Vice President
    AAPC Fullerton, CA Chapter

  8. #8
    Thanks for the info. This seems to be only affecting Jurisdiction 11 (J11)- Palmetto GBA- North Carolina, South Carolina, Virginia, West Virginia.

    Still getting no where on my end, waiting to hear back from provider services and the Palmetto GBA medical director.


  9. #9
    One of our patients called Medicare and was told there are no changes to the coverage for high risk colonoscopies.

    I am reaching out to CMS for clarification. Their address is below for anyone else who wants to contact them

    CMS, Atlanta Regional Office
    Information on local seminars and health fairs on Medicare health plan choices, or to report a complaint directly to CMS[/B].
    Areas Covered: AL, FL, GA, KY, MS, NC, SC, TN
    Regions: IV

    61 Forsyth Street, SW, Suite 4T20
    Atlanta, GA 30303

  10. #10
    Charlotte, NC
    It turns out Palmetto is using a "Draft" of NCD 210.3 that has an effective date of 10/1/2015.

    Like you had said, they are using the icd-9 to icd-10 conversion policy which is not complete on the "draft" obviously.

    We're going to start going through the appeals process tomorrow so I'll keep you updated the best I can.

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