Wiki Cologuard for Medicare

[thunbergiapixie@aol.com]

What are the cpt coding quidelines for billing cologuard for Medicare is just using the 81528 with modifier 33 or KX. Is there a G code that needs to bew billed with it?

 

[CBLENNIE]

There used to be a HCPCS code G0464 for Cologuard, but it was deleted effective 12/31/2015 with the permanent CPT code 81528 was created effective 01/01/2016. Per Medicare Claims Processing Manual Chapter 18-Preventive and Screening Services Section 60.2-Colorectal Cancer Screening HCPCS Codes, Frequency Requirements, and Age Requirements. The information regarding Cologuard is several pages into section 60.2.

• It is only covered for patients who are asymptomatic, are at average risk of developing CRC (no personal history of adenomatous polyps, colorectal cancer, or, inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancer adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).
• Coverage is limited to beneficiaries ages 45-85 (prior to 01/01/23 the covered ages was 50-85 but they changed it to start age 45 for services on or after 01/01/23).
• The covered DX codes are Z12.11 Encounter for screening for malignant neoplasm of colon, OR, Z12.12 Encounter for screening for malignant neoplasm of rectum.
• It is covered once every 3 years for beneficiaries who meet the criteria listed above.
• Since it is only covered for these 2 screening DXs there is no need to add modifier 33 or KX since Cologuard is only as a screening service which would be supported by DX codes Z12.11 & Z12.12.