Prepare for Colorectal Cancer Screening in 2015
March is National Colorectal Cancer Awareness month. Do your part by knowing the latest coding and billing guidelines.
By Renee Dustman
Fact No. 1:
Colorectal cancer affects both men and women, and is the leading cause of cancer deaths in the United States. (Newly upgraded from second place.)
Fact No. 2:
Colorectal cancer is highly preventable with regular screening, and treatable with early detection.
Colorectal cancer screening has been a Medicare Part B covered benefit since January 1, 1998. Acceptance and expectations for screening have evolved since then, spurring the invention of new tests and the necessity for new coverage guidelines.
Colorectal Cancer Screening Tests
Reflecting U.S. Preventive Services Task Force 2008 recommendations (2015 recommendations are in progress), colorectal cancer screening tests covered under Medicare Part B include:
- Fecal-occult blood test (FOBT);
- Barium enema;
- Flexible sigmoidoscopy; and most recently,
- Multi-target stool DNA test.
The Centers for Medicare & Medicaid Services (CMS) pays 100 percent of the Medicare-approved amount for FOBTs, flexible sigmoidoscopies, colonoscopies, and multi-target stool DNA tests, and 80 percent for barium enemas. A Part B deductible does not apply in any case. (Note: Coinsurance applies to colonoscopies and sigmoidoscopies performed in ambulatory surgical centers and non-Outpatient Prospective Payment System hospitals.)
Conditions of coverage for colorectal screening tests include age and frequency:
FOBT: Medicare covers this lab test once every 12 months for beneficiaries beginning at age 50. Effective January 27, 2014 ultrasounds for screening FOBTs is also a covered benefit.
Barium enema: Medicare covers this test once every 48 months for normal-risk beneficiaries age 50 or older; and for beneficiaries at high risk, once every 24 months. (There is no minimum age requirement for high-risk individuals to receive a barium enema in place of a screening colonoscopy.)
Colonoscopy: Medicare covers this test once every 120 months or once every 48 months after a previous flexible sigmoidoscopy; and for beneficiaries at high risk, once every 24 months. (There is no minimum age requirement for high-risk individuals to receive a screening colonoscopy.) Coverage for normal-risk individuals began July 1, 2001.
Effective January 1, 2015, beneficiary coinsurance and deductible are waived for anesthesia service 00810 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum when performed with a screening colonoscopy. Read Joette Derricks’, MPA, CMPE, CPC, CHC, CSSGB, article, “Good Coding News for Anesthesiologists in 2015,” for complete anesthesia coding guidance.
Flexible sigmoidoscopy: Medicare covers this test once every 48 months for most beneficiaries over age 50. For normal-risk patients, Medicare covers this test 120 months after a previous screening colonoscopy.
Multi-target stool DNA test: Effective January 1, 2015 Medicare covers this type of test once every 36 months when the following conditions are met:
- Age 50-85 years
- No signs or symptoms of colorectal disease
- At average risk, meaning:
- No personal history of adenomatous polyps, colorectal cancer, inflammatory bowel disease, including Crohn’s disease and ulcerative colitis
- No family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer
Who’s High Risk?
CMS considers a patient at high risk for colorectal cancer if he or she has any of the following:
- A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;
- A family history of adenomatous polyposis;
- A family history of hereditary nonpolyposis colorectal cancer;
- A personal history of adenomatous polyps;
- A personal history of inflammatory bowel disease, including Crohn’s disease and ulcerative colitis.
Note: Private payer policies may differ. For example, Aetna considers colorectal cancer screening beginning at age 45 a medically necessary preventive service for African Americans because of the high incidence rate of colorectal cancer in this population.
Another condition of payment is a written order from the beneficiary’s attending physician, or for claims with dates of service on or after January 27, 2014, the beneficiary’s attending physician assistant, nurse practitioner, or clinical nurse specialist. Proper procedure and diagnosis coding is a must.
For Medicare Part B claims, report colorectal cancer screening tests with the appropriate HCPCS Level II or CPT® code:
G0104 Colorectal cancer screening; flexible sigmoidoscopy
G0105 Colorectal cancer screening; colonoscopy on individual at high risk
G0106 Colorectal cancer screening; barium enema; as an alternative to G0104, screening sigmoidoscopy
82270 Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection)
G0120 Colorectal cancer screening; barium enema; as an alternative to G0105, screening colonoscopy
G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0122 Colorectal cancer screening; barium enema
G0328 Colorectal cancer screening; immunoassay, fecal-occult blood test, 1-3 simultaneous determinations
Note: Code GO122 is a non-covered service.
Indicate on the claim form the primary diagnosis for the screening test using an appropriate ICD-9-CM code (or ICD-10 code, after October 1). Code second any abnormalities found during the screening.
In accordance with the Affordable Care Act , Medicare waives the Part B deductible for colorectal cancer screening tests that become diagnostic. For services performed on or after January 1, 2011, append modifier PT A colorectal cancer screening test which led to a diagnostic procedure to the appropriate CPT® code.
The physician begins a screening colonoscopy on a Medicare patient, age 70, who is at normal risk for colorectal cancer. During the procedure, a polyp is detected and removed.
45385-PT Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
V76.51 Special screening for malignant neoplasms of colon
211.3 Benign neoplasm of the colon
When billing for a high-risk patient, the screening diagnosis code on the claim must reflect at least one high-risk condition.
Hope for the Future
Colorectal cancer screening is an effective and affordable method of prevention for this deadly disease. From 2001 to 2010, the incidence rate of colorectal cancer in the United States has decreased by 3.8 percent per year among men and 3.2 percent per year among women. Accurate coding will ensure patients receive proper and timely care at little to no cost to them.
G.J. Verhovshek, CPC, is managing editor at AAPC and a member of the Asheville-Hendersonville, North Carolina, local chapter.
Renee Dustman is executive editor at AAPC and a member of the Rochester, New York, local chapter.