october 2015

Screening Colonoscopy

How would you code the following colonoscopy procedure?

DIAGNOSIS: History of colon polyps
PROCEDURE: Colonoscopy

While I agree the patient presents without symptoms and has a history of polyps there are other factors that need to be taken into consideration before coding this case as a screening colonoscopy and/or determining whether or not to use G0105/G0121.

  1. Does the patient have a screening benefit? There are insurance plans that have been “grandfathered” under the Patient Protection and Affordable Care Act and these plans are not required to provide Preventive Services with a deductible waiver for their beneficiaries. Additionally, op notes have been dictated as a screening colonoscopy but the claim was still denied due to the fact that the patient did not have a screening benefit.
  2. Coverage Limitations. As you know, once a patient has had their initial screening colonoscopy there are specific time limitations before they are eligible for their next screening and that is based on whether or not the patient is deemed to be at “high risk” for developing colorectal cancer. A patient at high risk can have a screening procedure once every 24 months whereas a patient that is not at high risk may only have the exam once every 120 months or 48 months after a previous flexible sigmoidoscopy, but how many coders actually consider coverage limitations prior to assigning a screening colonoscopy code?
  3. Pathology. Let’s say for example, that this is a Medicare patient and the procedure is dictated as a screening colonoscopy - but the diagnosis remains “history of colon polyps” – how do you know whether you should report G0121 or G0105?

Medicare guidelines stipulate that for a patient to be at high risk they must have had;

  • A personal history of adenomatous polyps
  • A close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp

If you can’t verify the previous polyp as being hyperplastic or adenomatous then how can you assign the high risk code G0105? If the previous polyp(s) were hyperplastic the patient would not be at high risk, so has it been 10 years since their last screening colonoscopy as defined by the coverage limitations?

This also holds true for “family history of colon cancer” where the patient with a history has to be a sibling, parent or child. I have personally seen op notes where a high risk was dictated for an uncle or grandparent that had colon cancer, but a history for these individuals does not put the patient at a high risk according to the Medicare guidelines.

It is vitally important to verify insurance benefits and have the proper documentation to support the type of service being reported.

Noridian Healthcare Solutions has announced that it will be undertaking a Widespread Service Specific Probe with regards to CPT code 45378 in an effort to identify atypical billing and reduce the number of improper payments being made for this code..


About Us    |    Privacy-Security Statement    |    Terms of Use
© 2009 mdStrategies