Characteristics of High Risk and How Often Test can be Performed

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Dec 21st, 2015 - Reviewed/Updated Aug 7th

According to Medicares Pub-100, 60 - Colorectal Cancer Screening Ref: AB-03-114;

Screening colonoscopies (code G0105) may be paid when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered G0105 screening colonoscopy was performed). 

Characteristics of the High Risk Individual:

An individual at high risk for developing colorectal cancer has one or more of the following:

• A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;
  
  
• A family history of familial adenomatous polyposis;
  
  
• A family history of hereditary nonpolyposis colorectal cancer; 
  
  
• A personal history of adenomatous polyps;
  
  
• A personal history of colorectal cancer; or

• Inflammatory bowel disease, including Crohn’s Disease, and ulcerative colitis.

NOTE: If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than code G0105.

When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances, Medicare will pay for the interrupted colonoscopy as long as the coverage conditions are met for the incomplete procedure. (See CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 18, Section 60.2(A)(1) for additional information.)