Medicare billing CPT G0105,G0121 and covered diagnosis

Colonoscopy Coding - What Happens when a screening becomes diagnostic

Rely on G-Code for Medicare Screenings

Medicare requires that you report colonoscopy screening for eligible patients using either G0105 (Colorectal cancer screening;colonoscopy on individual at high risk) or G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk). These codes define a patient as either “high risk” for colorectal cancer, or “not meeting criteria for high risk.”

Medicare will allow only select diagnoses to support a high risk classification. These may include:

• V10.05 — Personal history of malignant neoplasm; gastrointestinal tract; large intestine

• V10.06 — Personal history of malignant neoplasm, rectum, rectosigmoid junction, and anus

• V12.72 — Personal history of certain other diseases; diseases of digestive system; colonic polyps

• V16.0 — Family history of malignant neoplasm; gastrointestinal tract

• V18.5 — Family history of certain other specific conditions; digestive disorders

Other Medicare- approved diagnoses for G0105 include inflammatory bowel disease, Crohn’s disease and ulcerative colitis.

If the patient meets any of the above criteria, you should list the appropriate risk factor as the primary diagnosis, along with procedure code G0105.

If the patient does not meet any of the high risk criteria for colorectal cancer, you would report procedure code G0121 with a primary diagnosis of V76.51 (Special screening for malignant neoplasms;colon).

For example, to report a covered colonoscopy screening for a 62-year-old male with a personal history of malignant neoplasm of the large intestine, you would link the “high risk” procedure code G0105 to a diagnosis of V10.05.

For an asymptomatic, 50-year-old patient receiving his first Medicare-covered colonoscopy screening, you would instead link a diagnosis of V76.51 to procedure code G0121