by Jared Staheli
July 5th, 2015
Payment is under the MPFS except as follows:
• Fecal occult blood tests (82270* (G0107*) and G0328) are paid under the clinical diagnostic lab fee schedule except reasonable cost is paid to all non-OPPS hospitals, including CAHs, but not IHS hospitals billing on TOB 83x. IHS hospitals billing on TOB 83x are paid the ASC payment amount. Other IHS hospitals (billing on TOB 13x) are paid the OMB approved AIR, or the facility specific per visit amount as applicable. Deductible and coinsurance do not apply for these tests. See section A below for payment to Maryland waiver on TOB 13X. Payment to all hospitals for non-patient laboratory specimens on TOB 14X will be based on the clinical diagnostic fee schedule, including CAHs and Maryland waiver hospitals.
• Flexible sigmoidoscopy (code G0104) is paid under OPPS for hospital outpatient departments and on a reasonable cost basis for CAHs; or current payment methodologies for hospitals not subject to OPPS.
• Colonoscopies (G0105 and G0121) and barium enemas (G0106 and G0120) are paid under OPPS for hospital outpatient departments and on a reasonable cost basis for CAHs or current payment methodologies for hospitals not subject to OPPS. Also colonoscopies may be done in an Ambulatory Surgical Center (ASC) and when done in an ASC the ASC rate applies. The ASC rate is the same for diagnostic and screening colonoscopies. The ASC rate is paid to IHS hospitals when the service is billed on TOB 83x.
The following screening codes must be paid at rates consistent with the rates of the diagnostic codes indicated. Coinsurance and deductible apply to diagnostic codes.
|Screening Code||Diagnostic Code|
|G0105 and G0121||45378|
|G0106 and G0120||74280|
A. Special Payment Instructions for TOB 13X Maryland Waiver Hospitals
For hospitals in Maryland under the jurisdiction of the Health Services Cost Review Commission, screening colorectal services HCPCS codes G0104, G0105, G0106, 82270* (G0107*), G0120, G0121 and G0328 are paid according to the terms of the waiver, that is 94% of submitted charges minus any unmet existing deductible, co-insurance and noncovered charges. Maryland Hospitals bill TOB 13X for outpatient colorectal cancer screenings.
B. Special Payment Instructions for Non-Patient Laboratory Specimen (TOB 14X) for all hospitals
Payment for colorectal cancer screenings (82270* (G0107*) and G0328) to a hospital for a non-patient laboratory specimen (TOB 14X), is the lesser of the actual charge, the fee schedule amount, or the National Limitation Amount (NLA), (including CAHs and Maryland Waiver hospitals). Part B deductible and coinsurance do not apply.
*NOTE: For claims with dates of service prior to January 1, 2007, physicians, suppliers, and providers report HCPCS code G0107. Effective January 1, 2007, code G0107 is discontinued and replaced with CPT code 82270.