Revenue Cycle Insider

Learn how often patients are eligible for a screening.

Correctly coding colorectal cancer (CRC) screenings is essential for ensuring proper reimbursement, preventing unexpected patient costs, and satisfying payer requirements.

With two-year old policy changes — especially the Centers for Medicare & Medicaid Services (CMS) updates in the 2023 Medicare Physician Fee Schedule (MPFS) and other Medicare/HCPCS policy changes — coders must understand when to report screening versus diagnostic services, which patients qualify for low- or high-risk screenings, when modifiers apply, and which ICD-10-CM codes support medical necessity.

This two-part series of articles breaks down those requirements and highlights the areas still under debate. In this part, Revenue Cycle Insider examines the types of eligible patients and lets you evaluate your knowledge with a real-world scenario.

Who Is Eligible for a Colorectal Cancer Screening?

Under the calendar year (CY) 2023 MPFS final rule, effective Jan. 1, 2023, CMS lowered the minimum Medicare-recognized age for all CRC screenings from 50 to 45, aligning with 2021 United States Preventive Services Task Force (USPSTF) recommendations.

Low-risk screening: A patient is considered low risk when they:

• Are asymptomatic,
• Have no personal or family history of colorectal cancer,
• Have no personal history of polyps,
• Have not had a colonoscopy in the last 10 years, and
• Have no chronic inflammatory bowel disease such as ulcerative colitis or Crohn’s colitis.

Your physician’s documentation should explicitly state the patient is asymptomatic and undergoing a routine screening.

High-risk screening: Patients are considered high risk when they are asymptomatic and:

• Have a personal or family history of CRC,
• Have a personal/family history of polyps, or
• Have ulcerative colitis or Crohn’s colitis requiring surveillance.

Other high-risk criteria listed by the American Gastroenterological Association (AGA) include hereditary nonpolyposis colorectal cancer (Lynch syndrome) and familial adenomatous polyposis (FAP).

Even though clinicians may describe these procedures as “surveillance,” coding rules consider them screening colonoscopies. Surveillance often means more frequent exams.

Diagnostic colonoscopy eligibility: On the other hand, a diagnostic colonoscopy is ordered because symptoms exist. Common symptoms include abdominal pain, changes in bowel habits, hematochezia, or a positive imaging/lab finding.

How Often Can Patients Receive a Screening?

For average-risk individuals, here are the industry standard screening frequency guidelines:

• Colonoscopy: Every 10 years. Medicare and commercial payers typically follow the 10-year interval unless findings shorten the interval (e.g., polyps)
• Fecal immunochemical test (FIT): Annually (every 12 months)
• High-sensitivity guaiac fecal occult blood test (gFOBT): Annually
• Stool DNA test (Cologuard™): Every three years (or once every 36 months), unless clinical findings warrant earlier testing
• CT colonography (“virtual colonoscopy”): Every five years — no commercial payer covers the test, and Medicare does not currently cover CT colonography for screening
• Flexible sigmoidoscopy: Every five years or every 10 years when combined with annual FIT

For high-risk patients, the frequency guidelines are different. Here are the standard guidelines:

• Colonoscopy: Every two to five years, depending on the type and number of prior polyps, dysplasia level, family history strength, type of hereditary syndrome, or inflammatory bowel disease (IBD) severity and years since diagnosis

Note: Medicare uses G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) for a high-risk screening colonoscopy and does not specify rigid intervals in its policy. Intervals must be clinically justified and documented.

• Screening after a positive noninvasive stool test: A positive FIT, gFOBT, or stool DNA test (e.g., Cologuard™) requires a follow-up colonoscopy. The colonoscopy should be performed as soon as medically possible (there is no “waiting interval”). Medicare and commercial payers consider the colonoscopy to be part of the screening process, not diagnostic. No cost-sharing may apply depending on payer and year (Medicare will phase out coinsurance fully by 2030). If the follow-up colonoscopy finds polyps, the next interval depends on pathology, which is generally three to seven years for adenomas.

What Is a Surveillance Colonoscopy?

Surveillance colonoscopies monitor patients with prior colorectal cancer, history of colorectal polyps, history of dysplasia, and IBD-associated colitis. These are not true screenings medically, but Medicare covers them as a screening, whereas commercial payers may treat them as diagnostic.

Typical intervals between surveillance colonoscopies depend on several factors:

• Prior CRC resection: One year after surgery, and then every three to five years
• History of adenomas:
  • One to two small tubular adenomas, every seven to 10 years
  • Three to 10 adenomas, every three years
  • Advanced adenoma, every three years
  • 10 adenomas, less than every three years (based on clinician’s judgment)
• IBD surveillance: If the patient has a longstanding disease (eight or more years), then every one to three years

Medicare generally follows these colonoscopy frequency rules:

• Every 10 years: G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk)
• Every two years: G0105, but this interval can vary based on medical necessity.

However, Medicare policies allow for frequency override when symptoms develop, new risk factors emerge, or pathology from a prior colonoscopy shortens the interval. Your physician’s documentation must clearly support the need for earlier testing.

Medicare diagnostic colonoscopy codes: Medicare accepts the full 45378-45398 (Colonoscopy, flexible …) range for diagnostic or therapeutic colonoscopies. Medicare will accept CPT^® colonoscopy codes when the intent or findings convert to diagnostic.

Try Your Hand at This Scenario

Suppose the patient had a positive:

• gFOBT (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)])
• iFOBT (G0328 [Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous]), or
• Cologuard™ (sDNA) (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])

Then, for commercial/Medicaid plans, you would use the diagnostic CPT^® code (such as 45378 [Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)]) and append modifier 33 (Preventive services) to report the diagnostic colonoscopy. Whereas you would use G0105 (high risk) or G0121 (not high risk) for a Medicare patient.

For Medicare, you must append modifier KX (Requirements specified in the medical policy have been met) with G0105/G0121 only when the colonoscopy follows a positive stool-based screening test. Otherwise, a straight screening colonoscopy may not require KX.

Important: Medicare will return G0105/G0121 claims without KX as unprocessable. Add the modifier and resubmit.

Next month in part 2 of the series, Revenue Cycle Insider will look at how you code screenings that become diagnostic or therapeutic encounters, as well as the appropriate ICD-10-CM codes to report for CRC screenings.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor