I am a Medicare A/R specialist for a large Gastro. group in Washington. I hope the following information helps!
Â· Screening flexible sigmoidoscopy: Medicare covers a screening flexible sigmoidoscopy once every 4 years for beneficiaries 50 and older. If a beneficiary had a screening colonoscopy in the previous 10 years, then the next screening flexible sigmoidoscopy would be covered only after 119 months have passed following the month in which the last screening colonoscopy was performed. A doctor of medicine or osteopathy, a physician assistant, a nurse practitioner, or a clinical nurse specialist may perform a screening flexible sigmoidoscopy.
Â· Screening colonoscopy: Medicare coverage for a screening colonoscopy is based on beneficiary risk. For beneficiaries 50 and older not considered to be at high risk for developing colorectal cancer, Medicare covers 1 screening colonoscopy every 10 years, but not within 47 months of a previous screening flexible sigmoidoscopy. For beneficiaries considered to be at high risk for developing colorectal cancer, Medicare covers 1 screening colonoscopy every 2 years, regardless of age. A screening colonoscopy must be performed by a doctor of medicine or osteopathy.
How to Bill Medicare
The following Healthcare Common Procedure Coding System/Current Procedure Terminology (HCPCS/CPT) codes should be used to bill for colorectal cancer screening services:
Colon cancer screening; flexible sigmoidoscopy
Colon cancer screening; colonoscopy on individual at high risk
Colon cancer screening; barium enema as an alternative to G0104
Colon cancer screening; FOBT, patient was provided 3 single cards or single triple card for consecutive collection
Colon cancer screening; barium enema as an alternative to G0105
Colon cancer screening; colonoscopy for individuals not meeting criteria for high risk
Colon cancer screening; barium enema (non-covered)
Colon cancer screening; fecal occult blood test, immunoassay
* When billing for the "high risk" beneficiary, the screening diagnosis code on the claim must reflect at least one of the high risk conditions mentioned previously. Examples of diagnostic codes are in the colorectal cancer screening chapter of the Guide to Preventive Services. This guide is available on the CMS website at: http://www.cms.hhs.gov/MLNProducts/downloads/PSGUID.pdf.
**Medicare covers colorectal barium enemas only in lieu of covered screening flexible sigmoidoscopies (G0104) or covered screening colonoscopies (G0105). However, there may be instances when the beneficiary has elected to receive the barium enema for colorectal cancer screening other than specifically for these purposes. In such situations, the beneficiary may require a formal denial of the service from Medicare in order to bill a supplemental insurer who may cover the service. These non-covered barium enemas are to be identified by G0122 (colorectal cancer screening; barium enema). Code G0122 should not be used for covered barium enema services, that is, those rendered in place of the covered screening colonoscopy or covered flexible sigmoidoscopy. The beneficiary is liable for payment of the non-covered barium enema.
If billing Carriers, the appropriate HCPCS and corresponding diagnosis codes must be provided on Form CMS-1500 (or the HIPAA 837 Professional electronic claim record).
If billing Intermediaries, the appropriate HCPCS, revenue, and corresponding diagnosis codes must be provided on Form CMS-1450 (or the HIPAA Institutional electronic claim record). Information on the type of bill and associated revenue code is also provided in the colorectal cancer screening chapter of the Guide to Preventive Services. Once again, this guide is available a on the CMS website t: http://www.cms.hhs.gov/MLNProducts/downloads/PSGUID.pdf. Reimbursement information is also provided in this guide.
I hope this was helpful!!
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