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Preventive Services: Colorectal Cancer Screening

By:  Find-A-Code
Published:  September 1st, 2017

The following information from the Medicare Learning Network provides guidance from the Department of Health and Human Services on Colorectal Cancer Screening: 

HCPCS/CPT Codes

81528 - Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result
82270 - Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided 3 cards or single triple card for consecutive collection)
G0104 Colorectal cancer screening; flexible sigmoidoscopy
G0105 - Colorectal cancer screening; colonoscopy on individual at high risk
G0106 - Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema
G0120 - Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema
G0121 - Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0328 - Colorectal cancer screening; fecal occult blood test, immunoassay, 1–3 simultaneous
G0464 - Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3)

ICD-10 Codes

See the CMS ICD-10 webpage for individual CRs and coding translations for ICD-10, and contact your MAC for guidance.

For multitarget sDNA test, use Z12.11 and Z12.12.

Who Is Covered

For colorectal cancer screening using multitarget sDNA test:

All Medicare beneficiaries who fall into all of the following categories:

  • Aged 50 to 85 years
  • Asymptomatic
  • At average risk of developing colorectal cancer

For screening colonoscopies, fecal occult blood tests (FOBTs), flexible sigmoidoscopies, and barium enemas:

All Medicare beneficiaries who fall into at least one of the following categories:

  • Aged 50 and older who are at normal risk of developing colorectal cancer
  • At high risk of developing colorectal cancer

NOTE: “High risk for developing colorectal cancer” is defined in the Code of Federal Regulations (CFR) at 42 CFR 410.37(a)(3)

NOTE: Coverage of screening colonoscopies has no age limitation

Frequency

For Beneficiaries Not Meeting Criteria for High Risk:

  • Multitarget sDNA test: once every 3 years
  • Screening FOBT: once every 12 months
  • Screening flexible sigmoidoscopy: once every 48 months (unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer and the beneficiary has had a screening colonoscopy within the preceding 10 years, in which case Medicare may cover a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that the beneficiary received the screening colonoscopy)
  • Screening colonoscopy: once every 120 months (10 years), or 48 months after a previous sigmoidoscopy
  • Screening barium enema (when used instead of a flexible sigmoidoscopy or colonoscopy): once every 48 months

For Beneficiaries at High Risk:

  • Screening FOBT: once every 12 months
  • Screening flexible sigmoidoscopy: once every 48 months
  • Screening colonoscopy: once every 24 months (unless a screening flexible sigmoidoscopy has been performed and then Medicare may cover a screening colonoscopy only after at least 47 months)
  • Screening barium enema (when used instead of a flexible sigmoidoscopy or colonoscopy): once every 24 months

Medicare Beneficiary Pays

81528, 82270, G0104, G0105, G0121, G0328, and G0464:

  • Copayment/coinsurance waived
  • Deductible waived

G0106 and G0120:

  • Copayment/coinsurance applies
  • Deductible waived

No deductible for all surgical procedures (CPT code range of 10000 to 69999) furnished on the same date and in the same encounter as a screening colonoscopy, flexible sigmoidoscopy, or barium enema initiated as colorectal cancer screening services.

Append modifier -PT to CPT code in the surgical range of 10000 to 69999 in this scenario.

Other Notes

  • Effective January 1, 2016, use CPT code 81528 when billing for Cologuard multitarget stool DNA (sDNA) test (note that your MAC will accept HCPCS code G0464 for claims with dates of service from October 9, 2014, to December 31, 2015). HCPCS G0464 expired effective December 31, 2015.
  • Append modifier -33 to the anesthesia CPT code 00810 when you furnish a separately payable anesthesia service in conjunction with a screening colonoscopy (G0105 and G0121) to waive Medicare beneficiary copayment/coinsurance and deductible.
  • When a screening colonoscopy becomes a diagnostic colonoscopy, anesthesia code 00810 should be submitted with only the -PT modifier, and only the deductible will be waived.

Please note: The information in this educational product applies only to the Medicare Fee-For-Service Program (also known as Original Medicare). For additional guidance on using diagnosis codes, go to the Medicare Claims Processing Manual, Chapter 18 on the Centers for Medicare & Medicaid Services (CMS) website.

Watch the CMS Provider Minute: Preventive Services video for pointers to help you submit sufficient documentation when billing for certain preventive services.


References:

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