Screening Colonoscopy

HCPCS code G0121 is required by CMS for any colorectal cancer screening colonoscopy on an individual not meeting criteria, (as listed above), for high risk.

HCPCS code G0105 is required by CMS for any colorectal cancer      screening colonoscopy on an individual at high risk.

HCPCS codes G0105 or G0121 can only be used with a principal diagnosis of Z12.11, screening for the malignant neoplasm of the colon. When a patient presents for a screening exam and there are abnormal findings, the abnormal findings are reported as secondary diagnoses.  The Z12.11 will always be the principal diagnosis on a screening exam.

CMS defines an individual at high risk as having a close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp, familial polyposis, nonpolyposis colorectal cancer, personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease including Crohn’s Disease or ulcerative colitis.

CMS and some commercial payors require modifier PT be used if a screening exam is converted to a therapeutic procedure.

If a payor does not follow CMS guidelines for coding screening exams; i.e. G0121, G0105, diagnostic codes are to be reported with modifier 33 (preventative services), 45378-33.

Modifier 33 should not be reported if the G code is used.

If a payor does not follow CMS guidelines for screening exams; i.e. G0121, G0105, diagnostic codes are to be reported with modifier 33 (preventative services), 45378-33.

If a screening exam is converted to a therapeutic procedure, the CPT code is reported with modifier PT.

Example: If a patient was admitted for a routine screening and a snare polyp removal of the ascending colon was performed you would not report the G-code, you would report diagnoses codes Z12.11, D122 and CPT code 45385-PT.

A surveillance colonoscopy is considered to be a high risk screening exam and can be reported with G0105.  All the rules regarding surveillance examinations follow the same rules as screening exams.

Screening/diagnostic exams

Any screening or diagnostic exam can result in a therapeutic procedure; that is one that is performed for definitive treatment. When a screening/diagnostic exam results in a therapeutic procedure, such as a biopsy or polypectomy, only the therapeutic procedures are reported.

A follow-up exam is a diagnostic/therapeutic exam that is performed to observe a previously treated condition, such as a polyp that is suspicious for cancer. The Coding Clinic’s example of follow-up exam has a short term post last examination, example given is six months.  Follow-up is reported as Z08 as the first listed diagnosis if the condition is not found, with the history code as a secondary diagnosis.  If the condition requiring follow-up has recurred report the condition as first listed diagnosis, in lieu of the Z08.