Colorectal Cancer Screening

Fecal Occult Blood Test

CPT and HCPCS:

  • 82270 - Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (e.g., patient was provided three cards or single triple card for consecutive collection)
  • G0328 - Fecal Occult Blood Test (FOBT), immunoassay, 1-3 simultaneous

Frequency:

Once every 12 months

82270 may be billed in place of G0328; however, both cannot be performed in same 12-month period

Coverage:

  • Aged 45 and older at normal risk for developing colorectal cancer; or
  • At high risk for developing colorectal cancer

Payment:

Copayment/coinsurance waived; Deductible waived

Cologuard Multitarget Stool DNA

CPT:

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

Frequency:

Once every three years

Diagnosis:

  • Z12.11 - Encounter for screening for malignant neoplasm of colon; and
  • Z12.12 - Encounter for screening for malignant neoplasm of rectum

Coverage:

  • Aged 45 and older
  • Asymptomatic
  • At average risk of developing colorectal cancer

Payment:

Copayment/coinsurance waived; Deductible waived

Complete Colorectal Cancer Screening

Screening colonoscopy following a positive result from non-invasive stool-based CRC screening test

  • A complete colorectal cancer screening is a flexibility that allows a colonoscopy that follows a positive result from a non-invasive stool-based CRC screening test to be billed as a screening procedure, not diagnostic.
  • Apply -KX modifier to the claim for the screening colonoscopy to identify the complete colorectal cancer screening context.

Flexible Sigmoidoscopy

HCPCS:

G0104 - Flexible Sigmoidoscopy

Frequency:

  • High risk: Once every 48 months
  • Not high risk: Once every 48 months (unless beneficiary does not meet criteria for high risk of developing colorectal cancer and beneficiary has had screening colonoscopy (G0121) within previous 10 years, screening flexible sigmoidoscopy is covered only after at least 119 months have passed following the month he/she received the G0121)

Coverage:

  • Aged 45 and older at normal risk for developing colorectal cancer; or
  • At high risk for developing colorectal cancer

Payment:

Copayment/coinsurance waived; Deductible waived

  • If screening turns to diagnostic with PT modifier appended, special coinsurance percentage phase-in; Calendar Year (CY):
    • CY 2023-2026, coinsurance 15%
    • CY 2027-2029, coinsurance 10%
    • Beginning CY 2030 and beyond, no coinsurance

Screening Colonoscopy

HCPCS:

  • G0105 - Colonoscopy (high risk)
  • G0121 - Colonoscopy (not high risk)

Frequency:

  • High risk: Once every 24 months (unless screening flexible sigmoidoscopy was performed, then covered only after at least 47 months)
  • Not high risk: Once every 10 years or 48 months after previous sigmoidoscopy

Payment:

Copayment/coinsurance waived; Deductible waived

  • If screening turns to diagnostic with PT modifier appended, special coinsurance percentage phase-in; Calendar Year (CY):
    • CY 2023-2026, coinsurance 15%
    • CY 2027-2029, coinsurance 10%
    • Beginning CY 2030 and beyond, no coinsurance

Surveillance Colonoscopy

Medicare does not specifically state whether a colonoscopy for "Surveillance" purposes is considered screening or diagnostic exclusively. Rather, it depends on the colonoscopy determination of billing:

  • Procedure reason and clinical circumstances

Example:

  • Patient has personal history of polyps and meets characteristics of high-risk individual
  • Physician states "surveillance" for next colonoscopy
    • Could be considered high-risk screening utilizing HCPCS G0105
  • Colonoscopy performed at three years and falls within interval timeframe for Medicare reimbursement

When a screening colonoscopy (routine or high-risk screening) procedure becomes more consistent with a diagnostic colonoscopy (based on findings, biopsy, additional required intervention, etc.), the coding will change to a diagnostic procedure. Append -PT modifier to signify the intraprocedural status change.

Screening Barium Enema

HCPCS:

  • G0106 - Barium Enema (alternative to G0104)
  • G0120 - Barium Enema (alternative to G0105)

Frequency:

  • High risk: Once every 24 months (when used instead of flexible sigmoidoscopy or colonoscopy)
  • Not high risk: Once every 48 months (when used instead of flexible sigmoidoscopy or colonoscopy)

Coverage:

  • Aged 45 and older at normal risk for developing colorectal cancer; or
  • At high risk for developing colorectal cancer

Payment:

Copayment/coinsurance applies; Deductible waived

High Risk Conditions

  • Close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp
  • Family history of familial adenomatous polyposis
  • Family history of hereditary nonpolyposis colorectal cancer
  • Personal history of adenomatous polyps
  • Personal history of colorectal cancer
  • Personal history of inflammatory bowel disease, including Crohn's Disease and ulcerative colitis

Screening Becomes Diagnostic

  • Use diagnostic CPT/HCPCS code
  • Primary diagnosis is screening; Secondary diagnosis indicates abnormal finding
    • Link second diagnosis to diagnostic code
  • Append modifier PT to indicate screening turned diagnostic
  • If screening turns to diagnostic with PT modifier appended, special coinsurance percentage phase-in; Calendar Year (CY):
    • CY 2023-2026, coinsurance 15%
    • CY 2027-2029, coinsurance 10%
    • Beginning CY 2030 and beyond, no coinsurance
  • Laboratory services associated with a diagnostic colonoscopy should bill an appropriate diagnosis that does not indicate screening. Modifiers PT and 33 are not used for lab or pathology services

Anesthesia and Colonoscopy

  • When a colonoscopy becomes diagnostic, anesthesia is reported using CPT 00811 with modifier PT. Bill with diagnostic CPT code (453xx series) and deductible only is waived
  • CPT 00812 (with no modifier) is used with screening codes. Both coinsurance and deductible are waived
  • Do not append modifier PT to other anesthesia CPTs 00730, 00740 and 00813
  • Modifier 33 is not recognized for any colonoscopy/anesthesia codes

Incomplete/Discontinued Procedure

  • Use modifier 53 to indicate a colonoscopy cannot be completed due to unforeseen circumstances. Billed amount must also be reduced upon claim submission. Medicare allows one-half the value of code billed
  • If a procedure is cancelled before any prep was completed, this cannot be billed for
  • Ambulatory Surgical Centers must append modifier 73 or 74 to indicate discontinued procedure prior to/after anesthesia administration

Evaluation and Management (E/M) Services

Example 1:

  • Dr. A referred a beneficiary for a screening colonoscopy. Since beneficiary is new to Dr. B, he/she would like to bill for an E/M visit and colonoscopy
  • If colonoscopy is performed same day as E/M, E/M is bundled into colonoscopy. E/M is not a separate, identifiable service. Beneficiary was evaluated by Dr. A before being sent to Dr. B. A second opinion or decision is not being requested, only the colonoscopy

Example 2:

  • Dr. A referred a beneficiary for a screening colonoscopy. On that day, beneficiary complained about stomach pain and loose, bloody stool so Dr. B did a full exam first
  • In this case, a new patient visit may be billed. Modifier 25 is not required on new patient visits

Noridian Medicare Portal

Yes - 81528, 82270, G0104, G0105, G0106, G0120, G0121 and G0328

Resources

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