Deductible and Coinsurance for Colorectal Cancer Screening (Rev. 3232, 01-05-15)

by  Jared Staheli
July 5th, 2015

There is no deductible and no coinsurance or copayment for the fecal occult blood tests (G0107 and G0328), flexible sigmoidoscopy (G0104), colonoscopy on individual at high risk (G0105), and colonoscopy on individual not meeting criteria of high risk (G0121). 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.

Prior to January 1, 2007 deductible and coinsurance apply to other colorectal procedures (G0106 and G0120). After January 1, 2007, the deductible is waived for those tests. Coinsurance applies.

Effective January 1, 2015, coinsurance and deductible are waived for anesthesia services HCPCS Code 00810, Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum, when performed for screening colonoscopy services and when billed with Modifier 33.

NOTE: A 25 percent coinsurance applies for all colorectal cancer screening colonoscopies (G0105 and G0121) performed in ASCs and non-OPPS hospitals effective for services performed on or after January 1, 2007. The 25 percent coinsurance was implemented in the OPPS PRICER for OPPS hospitals effective for services performed on or after January 1, 1999.

A 25 percent coinsurance also applies for colorectal cancer screening sigmoidoscopies (G0104) performed in non-OPPS hospitals effective for services performed on or after January 1, 2007. Beginning January 1, 2008, colorectal cancer screening sigmoidoscopies (G0104) are payable in ASCs, and a 25 percent coinsurance applies. The 25 percent coinsurance for colorectal cancer screening sigmoidoscopies was implemented in OPPS PRICER for OPPS hospitals effective for services performed on or after January 1, 1999.

References:

• Pub 100-04 Medicare Claims Processing Manual - Chapter 18