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Colonoscopy with family history of colon cancer

  1. #1
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    You should bill this as G0105 and V16.0. The G0105 states it is a screening colonoscopy for a patient at high risk, and the V16.0 establishes the high risk criteria. This service is paid every two years. If you bill using V76.51 you are using the code CMS requires for the average risk colonoscopy and is payable every10 years.
    Jenny Berkshire, CPC, CEMC, CGIC

  2. #2
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    I respectfully disagree. I would code the V76.51 with the V16.0 as a secondary.

    Screening colonoscopy: Medicare coverage for a screening colonoscopy is based on beneficairy 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.

    I found this info in a post on this website some time ago and it has proved to be very useful.

    You can find more info on the following website for CMS. It is provided in the colorectal cancer screening chapter of the guide to preventative services found here:

    http://www.cms.hhs.gov/MLNProducts/downloads/PSGUID.pdf.

    I always use the V76.51 along with the V16.0 and it always gets paid by Medicare. And, the only time I don't use a G code is when there is a polyp removed or a biopsy doen, etc. Hope this helps. It's just another side of the coin, I guess.

  3. #3
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    This subject is certainly debatable and open to interpretation. I would still list the family history diagnosis first. See the ICD-9 official coding guidelines which indicate: "Family history codes are for use when a patient has a family member(s) who has had a particular disease that causes the patient to be at higher risk of also contracting the disease." http://www.cdc.gov/nchs/data/icd9/icdguide09.pdf, page 72.
    Jenny Berkshire, CPC, CEMC, CGIC

  4. Smile debbiew
    I totally agree with the berkshire reply

  5. #5
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    Such a debatable issue. However, I reviewed both links provided above and agree that for a Medicare with a family history, this makes them high risk and Medicare does accept V16.0 as the primary dx code with G0105. Most other insurances don't. Just one more way CMS adds to our coding confusion...
    Lisa Bledsoe, CPC, CPMA

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