Colorectal Cancer Screening Tests
by John Verhovshek, CPC, and Renee Dustman
Reflecting United States Preventive Services Task Force (USPSTF) 2008 recommendations (2015 recommendations are in progress), Medicare Part B covers 100 percent of the Medicare-approved amount for fecal occult blood tests, flexible sigmoidoscopies, colonoscopies, and multi-target stool DNA tests, and 80 percent for barium enemas for colorectal cancer screens. 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:
- Fecal occult blood test: Medicare covers this lab test once every 12 months for beneficiaries beginning at age 50. Effective January 27, 2014 ultrasound screening for screening FOBTs is also a covered benefit.
- Barium enema: Medicare covers this test once every 48 months for normal-risk beneficiaries aged 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.
Tip: 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 in with a screening colonoscopy.
- 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.
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 (non-covered)
G0328 Colorectal cancer screening; immunoassay, fecal-occult blood test, 1-3 simultaneous determinations
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