High-Risk Colonoscopy Patients: Criteria and Coding Changes
CMS frequently reviews and updates its guidelines for screening colonoscopies. Patients who undergo screening colonoscopies for colorectal cancer fall into two categories: high risk and not high risk (also considered average risk). Both coding and coverage are affected by how an individual is identified, which is why it is important for ASCs that perform colonoscopies to be aware of recent changes by Medicare to how high-risk colonoscopy patients are defined and their procedures coded.
an individual at high risk for developing colorectal cancer must have 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.
Based on these guidelines, if a patient is documented as having a personal or family history of polyps, they still do not meet the criteria for high risk unless those polyps are documented as adenomatous. The American Medical Association has created new ICD-10-CM diagnosis codes for historical familial colonic polyps to quickly differentiate the condition as meeting the criteria for high risk.
The new ICD-10-CM codes for colonic polyps are as follows:
Z83.710 Family history of adenomatous and serrated polyps
Z83.711 Family history of hyperplastic colon polyps
Z83.718 Other family history of colon polyps
Z83.719 Family history of colon polyps, unspecified
If the patient’s operative report doesn’t specify that the historical polyps were adenomatous, then the screening is coded with HCPCS G0121" "Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk."
Payers have limitations on the frequency and necessity of screening colonoscopies for individuals who are not high risk, so make sure you are on the same page with your physician about the plan of care and the criteria for high-risk individuals. When you are performing a colonoscopy on a high-risk individual, ensure the patient's history is appropriately documented.