Coding Colorectal Cancer Screening
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
- 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
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:
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.
The deductible and coinsurance will be waived for new CPT code 00812 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy beginning Jan. 1, 2018, and for claims with new CPT code 00811 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified the deductible will be waived when submitted with modifier PT.
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.
MLN Education Tool, Medicare Preventive Services, Colorectal Cancer Screening
CMS Transmittal 3844
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