If you slip up on screening colonoscopy claims’ frequency guidelines and eligibility requirements, Medicare will pay you zilch.
Use this guidance to capture every screening dollar your gastroenterologist deserves.
Home in on Eligibility Requirements for Average-Risk Test
Any Medicare patient 50 years or older is eligible for a covered Medicare screening, explains Dena Rumisek, CPC, biller at Grand River Gastroenterology PC in Michigan. These patients can have a colorectal cancer screening only once every 10 years. You’d be wise to pay attention to the frequency guidelines, as “Medicare is very stringent on the date … it has to be 10 years or longer — it can’t be 9 years and 360 days” between covered screening colonoscopies, Remise warns.
Example: A 73-year-old established Medicare patient with average risk for colorectal cancer reports for a screening colonoscopy on Feb. 11, 2009. The patient’s records indicate that he last had a covered screening on Jan. 31, 1999. On the claim, you should report G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).
One bit of simplicity: Report G0121 if there is no need for any therapeutic intervention during the colonoscopy. All G0121 claims require only one diagnosis code: v76.51 (Special screening for malignant neoplasms; colon). “If the chart shows a diagnosis such as colitis, you shouldn’t be reporting a screening,” says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA’s CPT Advisory Panel.
Error averted: The chart notes and the procedure diagnosis should be consistent. “This is something the OIG and RAC auditors are scrutinizing,” Weinstein says.
Change Your Coding for Recent Sigmoidoscopy
The frequency rules differ depending on whether other related colorectal cancer tests were performed previously. If a patient has had a routine...
- Free updates on CPT, ICD-9, HCPCS, Medicare, NCCI edits, and ICD-10.
- Discounts on 3rd party offers