Coding Colorectal Cancer Screening
- By Renee Dustman
- In CMS
- March 2, 2018
- 18 Comments
What better time to refresh your coding know-how for colorectal cancer screening than National Colorectal Cancer Awareness month?
Of cancers that affect both men and women, colorectal cancer is the second leading cause of cancer-related deaths in the United States, according to the Centers for Medicare & Medicaid Services (CMS). Screening can help find this cancer at an early stage, when treatment often leads to a cure.
Colorectal cancer screening is a Medicare preventive service.
HCPCS Level II and CPT Procedure Codes
- 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
- 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)
- G0104 –
- Colorectal cancer screening; flexible sigmoidoscopy
- G0105 –
- Colorectal cancer screening; colonoscopy on individual at high risk
- G0106 –
- Colorectal cancer screening; alternative to g0104, screening sigmoidoscopy, barium enema
- G0120 –
- Colorectal cancer screening; alternative to g0105, screening colonoscopy, barium enema
- G0121 –
- Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
- G0328 –
- Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous
-
ICD-10 Diagnosis Codes
For multi-target stool DNA (sDNA) test, use Z12.11 Encounter for screening for malignant neoplasm of colon and Z12.12 Encounter for screening for malignant neoplasm of rectum.
See NCD 210.3 for a full list of applicable diagnosis codes.
Who is Covered
For colorectal cancer screening using multitarget sDNA test, coverage applies to all Medicare patients who fall are:
- Aged 50 to 85 years
- Asymptomatic
- At average risk of developing colorectal cancer
For screening colonoscopies, fecal occult blood tests (FOBTs), flexible sigmoidoscopies, and barium enemas, coverage applies to all Medicare patients who fall into at least one of the following categories:
- Aged 50 and older who are at normal risk of developing colorectal cancer
- At high risk of developing colorectal cancer
Frequency
For patients not meeting criteria for high risk, frequency limitations are:
- Multitarget sDNA test: once every 3 years
- Screening FOBT: once every 12 months
- Screening flexible sigmoidoscopy: once every 48 months (unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer and the beneficiary has had a screening colonoscopy within the preceding 10 years, in which case Medicare may cover a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that the beneficiary received the screening colonoscopy)
- Screening colonoscopy: once every 120 months (10 years), or 48 months after a previous sigmoidoscopy
- Screening barium enema (when used instead of a flexible sigmoidoscopy or colonoscopy): once every 48 months
For patients at high risk, frequency limitations are:
- Screening FOBT: once every 12 months
- Screening flexible sigmoidoscopy: once every 48 months
- Screening colonoscopy: once every 24 months (unless a screening flexible sigmoidoscopy has been performed and then Medicare may cover a screening colonoscopy only after at least 47 months)
- Screening barium enema (when used instead of a flexible sigmoidoscopy or colonoscopy): once every 24 months
Medicare Patient Cost-Sharing
For 81528, 82270, G0104, G0105, G0121, and G0328, the following is waived:
- Copayment/coinsurance
- Deductible
For G0106 and G0120:
- Copayment/Coinsurance applies
- Deductible is waived
No deductible applies for all surgical procedures (CPT 10000 – 69999) furnished on the same date and in the same encounter as a screening colonoscopy, flexible sigmoidoscopy, or barium enema initiated as colorectal cancer screening services. Append modifier PT Colorectal cancer screening test; converted to diagnostic test or other procedure to the CPT code.
Append modifier 33 or PT to moderate sedation codes G0500 and +99153 when moderate sedation is furnished in conjunction with screening colonoscopy services to waive the patient’s Medicare copayment/coinsurance and deductible.
Source:
MLN Education Tool, Medicare Preventive Services, Colorectal Cancer Screening
CMS Transmittal 3844
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I believe it should be a correction in the end of the article. isn’t should be 00811 instead of 00810?
isn’t the 00810 deleted for 2018?
Yes, thank you for the correction. The information has been corrected in the article.
No matter if mod 33 or PT is added, +99153 is only billable by the facility not the physician her/himself so the statement above does not cover all scenarios.
What is code 84270 and code 84403 represents.
My father 62 years old diabetic had a fasting blood work done, these codes are indicated on the description sent from the insurance company. He did not request these tests, or is it a normal procedure when testing blood work.
Hi Sandy,
Those are CPT codes. I recommend you contact your father’s physician to find out why those were reported.
I had a preventative colonoscopy and was told there was no co-pay. Afterwards they charged me $1,652 because they said they found a polyp so it was no longer preventative but now diagnostic. I believe it should have been coded as preventative with PT at the end and I shouldn’t be charged or they should have told me of possible charges ahead of time. I specifically asked ahead if time if I would be billed as diagnostic if they found a polyp and I was assured by the scheduler that it could not be switched from preventative to diagnostic if they did a biopsy.
Darcy, what was the reason for the colonoscopy? Did you have any symptoms? Or family or personal history of polyps? Or just screening after 50?
I’m trying to look up reimbursement for cpt 00811 and 00812 – anesthesia for colonoscopy – and CMS physician fee schedule states, “The current Physician Fee Schedule does not price the requested HCPCS Code(s).”
I need a dollar amount for my carrier, WPS. It appears that there is additional info needed that CMS isn’t set up for. I’m interested in hospital facility and Anesthesia professional (not gastroenterologist) service
Patient presents for screening colonoscopy at 5 yrs as polyps were found on first colonoscopy 5 years previous. Physician’s office and hospital billed as a screening colonoscopy with primary diagnosis Screening secondary diagnosis Personal history of polyps. The anesthesia billing company is billing patient as this was not a screening but a surveillance colonoscopy. It is my understanding that high risk patients in most circumstances may receive a screening colonoscopy at 24 months. What can I present to this company to help them understand and keep the patient from being billed?
Amy, I agreed with the insurance- it is not a screening.
So you have to code as personal history icd code ( if the polyp was removed) or code for the polyp.
Pr is a high risk pt- pt it will get the bill.
Personal history of colon polyps is first… since the polyp it was removed.
I am trying to look for M2 PK stool tumor marker test, where i couldn’t find any specific cpt code for that. Can you confirm if it would be 81528?
In regards to Nina and Amy: First quarter 2017 coding Clinic page 9 advises on this exact scenario and states that Z12.11 would be the primary and the history of colon polyps would be the secondary. Because a surveillance colonoscopy is still a screening, it’s just considered a high-risk screening due to the history. So I am curious as to what your rationale is for not listing Z12.11 as the primary diagnosis since the patient is outside of the 24 month wait period for screenings?
Heather, That was my understanding as well. This is the way the billing was submitted. Thank you for confirmation.
Not in accordance with the AAPC gastroenterology specialty book.
If the pt has family hx- the pt is a high risk patient.
Therefore not a screening!
Should modifier PT/33 be appended to all cpt codes for example: patient had polypectomy (45385) and biopsy (45380) or just the primary (45385) cpt code?
Thank you
who gets credit for the FOBT when it is turned in and interpreted? one provider may issue the kit, but another provider is present when kit returned and interpreted, thx!
Hello, does a patient with a personal history of rectal cancer qualify for a screening every 12 months?