Colorectal Cancer Screening Tests

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:

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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

Renee Dustman

Renee Dustman

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.
Renee Dustman

About Has 425 Posts

Renee Dustman is executive editor at AAPC. She has a Bachelor of Science degree in Journalism and a long history of writing just about anything for just about every kind of publication there is or ever has been. She’s also worked in production management for print media, and continues to dabble in graphic design.

One Response to “Colorectal Cancer Screening Tests”

  1. kingstonGA says:

    Thank you !!!! very Keen informative. Colon cancer is one of the silent killers ! Don’t wait until you suspect something is wrong. Go early ….stay healthy ! Visit http://colorectal-surgeon.com.au/

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