Wiki Positive Cologuard

[rebelhotspur]

Just asking as one of my doctors pulled me up on this - that insurances are not allowing positive Cologuard tests to hinder the billing of a subsequent screening. As far as I was aware, +Cologuard made the next colonoscopy a diagnostic procedure. I keep seeing different things online - could anyone please clarify what the current status is?

Many thanks.

 

[nickelclaw]

https://www.mediclaimservices.com/our-coding-blog/screening-vs-diagnostic-colonoscopies

you are correct

The Cologuard is the diagnostic Z12.11 abnormal findings R19.5 with Z12.11 as primary;
when there are abnormal findings the next colonoscopy is diagnostic with primary dx R19.5 if no findings,
if findings then admit R19.5 and then finding as primary

 

[lamiller]

Can someone clarify this for me? We are having a discussion with our providers over this and need to know what to tell them? If a patient has a positive cologuard test how do I then code it as a screening? Do I code Z12.11 then R19.5? I know there is certain eligibility rules in place as far as when the insurance was active. I just can't get a straight answer from anyone on this matter. Thanks for help in advance.

 

[lgardner]

I just watched a Noridian webinar on the Medicare Quarterly Updates and this topic came up.

Medicare Physician Fee Schedule Final Rule Summary: CY 2023:

"Expansion of Coverage for Colorectal Cancer Screening and Reducing Barriers
For CY 2023, we’re modifying our policies to expand coverage of colorectal cancer (CRC) screening in 2 ways:
• First, we’re modifying coverage and payment requirements for certain CRC screening tests to start when the individual is 45 years of age or older, including Blood-based Biomarker Tests, The Cologuard™ – Multi-target Stool DNA (sDNA) Test, Immunoassaybased Fecal Occult Blood Test (iFOBT), Guaiac-based Fecal Occult Blood Test (gFOBT), MLN Matters: MM12982 Related CR 12982 Page 4 of 7 Barium Enema Test, and Flexible Sigmoidoscopy Test. Screening Colonoscopy will continue with no minimum age limitation. We aren’t modifying existing maximum age limitations.
• Second, we’re expanding the regulatory definition of CRC screening tests to include a follow-on screening colonoscopy after a Medicare covered non-invasive stool-based CRC screening test returns a positive result. We added the regulatory definition to 42 CFR 410.37.

See MLN Matters Article MM12656 for more information"

the presenter on the webinar stated that, while if a patient has a positive FOBT or Cologuard, they could still have a screening colonoscopy, BUT she didn't have any guidance (at the moment) regarding how to list the diagnoses.

 

[chefspring@yahoo.com]

Patients that have a positive Cologuard screening can still have a screening colonoscopy. A modifier KX will need to be appended to the screening colonoscopy following the positive non-invasive stool based test (Cologard).

Taken from Novitas: https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00008244

Colorectal cancer screening (CRC)​

Effective with dates of service on and after January 1, changes occurred for CRC:

Reduction in coinsurance when a screening colorectal cancer becomes diagnostic
Minimum age for colorectal cancer screening tests from 50 to 45
Colorectal cancer screening tests include a follow-on screening colonoscopy if a non-invasive stool-based test returns a positive result.
Report the KX modifier on colorectal cancer screening tests including a screening colonoscopy (HCPCS codes G0105, G0121) after a non-invasive stool-based test (HCPCS codes 82270, G0328 and 81528).
The KX modifier needs to be reported on the screening colonoscopy claim. Deductible and coinsurance do not apply to the non-invasive stool-based tests nor the screening colonoscopy because both tests are specified preventive screening services.