Results 1 to 7 of 7

Medicare Colonoscopy Rules

  1. #1
    Default Medicare Colonoscopy Rules
    Exam Training Packages
    I do not know if this question has been posted before...forgive me if it has but I can't find an answer anywhere.
    I have a claim that was denied by Medicare because G0121 (DOS 04/06/11) was billed a little over a year from when 45378 was billed (DOS 03/12/10). The denial states "benefit maxmium for this time period or occurance has been reached".
    My question is this, does Medicare allow G0121 to be billed when 45378 was billed about 12 months prior?
    Thank you in advance for your help!!

  2. #2
    Default
    G0121 can be billed once every 10 years. Verify that the 45378 was billed for a problem and not screening (it should be a problem). If it was billed for a problem then they must have had a screening colo in the last ten years or even a flex sig. Medicare is pretty good about keeping up with this stuff. I have never known them to deny one of these for this reason in error but that has just been my experience. Hope this helps!
    Susie Corrado, CPC
    __________________
    ENT Coding/Billing

  3. #3
    Default
    This really helps Susie. I really appreciate your response!

  4. #4
    Default
    One additional thought: did another provider, perhaps their PCP provide the G0121 in that time span?
    Jenny Berkshire, CPC, CEMC, CGIC

  5. Default
    Although the colon codes and reasons may have differed, even a medically necissary colonoscopy being performed within the 10 year period would remove the necessity to have a screening unless the patient has a high risk indicator or a medically necessary reason for the follow up procedure.

  6. #6
    Default
    Jenny,
    I do not know if her PCP provided the screening. Our general surgeon has only seen her twice, once for the colonoscopy in March 2010 and the screening in April 2011.

  7. Default
    Unless the patient had a high risk indicator for the 2011 procedure such as a personal or family history of polyps, ect. then you will likely be looking at a valid denial from Medicare because the procedure was definitely not necessary.

Similar Threads

  1. Opting out of Medicare Rules
    By Barbaraw in forum Compliance General Discussion
    Replies: 0
    Last Post: 12-02-2010, 12:08 PM
  2. new medicare rules
    By jennyjlm in forum E/M
    Replies: 1
    Last Post: 02-09-2010, 01:30 PM
  3. Medicare Rules for Anesthesia
    By reichtina320 in forum Anesthesia
    Replies: 3
    Last Post: 09-03-2009, 07:26 AM
  4. Medicare's rules??
    By poohdp01 in forum Medicare Regulations
    Replies: 5
    Last Post: 08-30-2009, 08:32 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.