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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
    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
    This really helps Susie. I really appreciate your response!

  4. #4
    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
    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.

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