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G0105 vs G0121 HELP??

  1. #1
    Default G0105 vs G0121 HELP??
    Medical Coding Books
    Patient came in for colon due to personal hx of colon polyps, last colon was in 2005 with polyps being removed. This time the patient did not have polyps so i coded the colon as:
    G0105 ,v12.72. Patient is disputing her charge because the insurance company told her that it was not coded correctly and if it had been coded as a screening it would have paid 100%. The patient is stating that her ins company (cigna st of tn) told her it should have been coded as a "yearly" screening. These screening colons are very confusing, and the ins companies are not helping. Should i have done this differently???

  2. Default hi
    hi Karileigh;

    This should be coded only 45378 with diagnosis v12.72. No need G0121 or G0105. If you want anymore clarification please send whole documentation so i can explain you better. Hope this will help.

  3. #3
    ok, thanks , it still puts its as a medical and the patient would not get the 100% benefit of the screening????

    Again thanks for the feedback


  4. #4
    Mesa Arizona
    That depends if the patient has coverage in their policy for high risk screening/ surveillance. Most insurance carriers do not consider this scenario preventive screening because time intervals between colonoscopies are shortened from the standard 10 years. Ultimately it is up to the insurance company determine what each indivudials benefits are payable. The patient always has the option to appeal the decision.

    It is also important to keep up with the current release of medical coverage determinations (preventive care services/colorectal cancer screenings) for each carrier. Many of them are adapting them to exclude personal history of polyps from a preventive screening benefit for the above mentioned reason. These determinations can be used as explanation tools for patients.

  5. Default
    If the physcian documents the charge as a routine screening due to a patient Hx of polyps it would support the addition of the primary code V76.51 followed by the Hx (V12.72). By the ACA (Affordable Care Act) Inacted into Law 01/01/2011. These High risk indicators should be viewed as routine, however to work with the payor guidelines you need to start with proper documentation not only from the physician, but all points of patient care. I.e. scheduling, reffering, and intake. All departments should be educated as to how the documentation should be to maximize proper reimbursemnt from the payors. A lot of new guidelines have been put into place within the last couple of years. After a six month process of research of the federal and state laws for routine coverage as well as CMS guidelines we have been able to restructure our entire process from begining to end to not only increase our reimbursement, but to advocate the bast care possible for the patient as well.

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