(Medicare Claims Processing Manual)

Effective  for services  furnished on or after October  9, 2014, the following code  is added  for colorectal cancer screening services:   HCPCS G0464 -  Colorectal cancer  screening; stool -based DNA and fecal occult hemoglobin (e.g., KRAS,  NDRG4  and BMP3).  Effective January  1, 2016, HCPCS  G0464 is discontinued and replaced with CPT 81528.  Effective  for services  furnished on or after January 19, 2021, the following code  is added  for colorectal cancer services:   HCPCS  G0327 - Colorectal  cancer  screening;  blood- based  biomarker  Colon  ca scrn;bld-  bsd biomrk Effective for claims with dates of service on or after January 1, 2023, the frequency limitations for screening colonoscopy (HCPCS codes G0105, G0121) shall not apply when the screening colonoscopy follows  a positive  result  from  a non-invasive  stool -based  test (HCPCS  codes  82270, G0328 and 81528). This scenario is identified when the furnishing practitioner submits the screening colonoscopy claim with the KX modifier. See 42 CFR 410.37(k).   *NOTE : For claims with dates of service prior to January 1, 2007, physicians, suppliers, and providers  report  HCPCS  G0107. Effective  January 1, 2007, HCPCS  G0107 is discontinued and replaced with CPT 82270. G0104  Colorectal  Cancer Screening;  Flexible  Sigmoidoscopy Screening flexible sigmoidoscopies (HCPCS G0104) may be paid for beneficiaries who have attained  age 50, when  performed  by a doctor  of medicine  or osteopathy at the frequencies  noted below.  For claims with dates of service on or after January 1, 2002, A/B MACs (A) and (B) pay for screening  flexible  sigmoidoscopies  (HCPCS  G0104)  for beneficiaries  who have  attained  age 50 when these services were performed by a doctor of medicine or osteopathy, or by a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) (as defined in  1861(aa)(5)  of the Social  Security  Act (the Act) and  in the Code  of Federal  Regulations  (CFR) at 42 CFR  410.74, 410.75, and 410.76)  at the frequencies  noted above. For claims  with dates  of service prior to January 1, 2002, Medicare Administrative Contractors (MACs) pay for these services under the conditions noted only when a doctor of medicine or osteopathy performs them.  For services furnished  from January 1, 1998, through June  30, 2001, inclusive:    Once every  48 months  (i.e., at least 47 months  have passed  following the month in which the last covered screening flexible sigmoidoscopy was performed).   For services furnished  on or after  July 1, 2001:    Once every 48 months as calculated above unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer (refer to 60.3 of this chapter) and he/she  has had a screening  colonoscopy (HCPCS  G0121)  within  the preceding  10 years.  If such a beneficiary  has had a screening  colonoscopy within  the preceding  10 years,  then he or she can have covered a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that he/she received the screening colonoscopy (HCPCS G0121).  Effective  for claims  with dates  of service  on or after January  1, 2023, the minimum age for screening flexible sigmoidoscopy is reduced to 45 years and older.   NOTE:  If during the course of a screening  flexible  sigmoidoscopy a lesion  or growth is detected which results in a biopsy or removal of the growth; the appropriate diagnostic procedure classified as a flexible sigmoidoscopy with biopsy or removal along with modifier - PT should be billed and paid rather than HCPCS G0104. HCPCS  G0105  Colorectal  Cancer;  Colonoscopy on Individual  at High  Risk  Screening colonoscopies (HCPCS code G0105) may be paid when performed by a doctor of medicine  or osteopathy at a frequency  of once  every  24 months  for beneficiaries  at high risk  for developing colorectal  cancer  (i.e., at  least  23 months  have  passed  following the month in  which the last covered HCPCS G0105 screening colonoscopy was performed). Refer to 60.3 of this chapter for the criteria to use in determining whether or not an individual is at high risk for developing colorectal cancer.  NOTE:  If during the course of the screening  colonoscopy, a  lesion  or growth is detected  which results  in a biopsy or removal  of the growth, the appropriate  diagnostic  procedure  classified  as a colonoscopy with biopsy or removal along with modifier - PT should be billed and paid rather than HCPCS G0105.  A. Colonoscopy Cannot  be Completed  Because of Extenuating  Circumstances  1. A/B MACs  (A) When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances, Medicare will pay for the interrupted colonoscopy as long as the coverage conditions are met for the incomplete procedure. However, the frequency standards associated with screening  colonoscopies  will not be applied  by the Common Working File (CWF).  When  a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according  to its payment methodology for this procedure  as long as coverage conditions  are met, and the frequency standards will be applied by CWF. This policy is applied to both screening and diagnostic  colonoscopies. When  submitting  a facility  claim  for the interrupted  colonoscopy, providers are to suffix the colonoscopy.  Use of HCPCS codes with a modifier of - 73 or - 74 is appropriate to indicate that the procedure was interrupted. Payment for covered incomplete screening colonoscopies shall be consistent with payment methodologies currently in place for complete screening colonoscopies, including those  contained  in 42 CFR  419.44(b). In situations  where a CAH  has elected  payment  Method II for CAH patients, payment shall be consistent with payment methodologies currently in place as outlined in chapter  3 of this manual.  As such, instruct  CAHs  that elect  Method II  payment  to use modifier - 53 to identify an incomplete screening colonoscopy (physician professional service(s) billed in revenue code 096X, 097X, and/or 098X).  Such CAHs will also bill the technical or  facility  component  of the interrupted colonoscopy  in revenue  code  075X  (or other  appropriate revenue code) using the - 73 or - 74 modifier as appropriate.  Note that Medicare would expect the provider to maintain adequate information in the patients medical  record  in case it is needed  by the A/B MAC  (A) to document  the incomplete  procedure.  2. A/B MACs  (B) When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances (see chapter 12, section 30.1), Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one- half the value of the inputs for the code s. The MPFS database has specific values for codes 44388- 53, 45378- 53, G0105- 53 and G0121- 53. When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to its payment methodology for this procedure  as long as coverage conditions  are met. This policy  is applied to both screening and diagnostic  colonoscopies. When submitting a claim for  the interrupted colonoscopy, professional  providers  are to suffix  the colonoscopy code  with a modifier of - 53 to indicate that the procedure was interrupted. When submitting a claim for the facility fee associated with this procedure, ASCs) are to suffix the colonoscopy code with modifier  -73 or -74 as  appropriate.  Payment  for covered  screening  colonoscopies, including that for the associated ASC facility fee when applicable, shall be consistent with payment for diagnostic colonoscopies, whether the procedure is complete or incomplete. Note that Medicare would expect the provider to maintain adequate information in the patients medical  record  in case it is needed  by the A/B MAC  (B) to document  the incomplete  procedure.  HCPCS  G0106  Colorectal  Cancer Screening;  Barium  Enema;  as an Alternative to HCPCS G0104, Screening Sigmoidoscopy  Screening  barium  enema  examinations  may be paid as an alternative  to a screening sigmoidoscopy (HCPCS G0104). The same frequency parameters for screening sigmoidoscopies (see those codes above) apply. In the case of an individual aged 50 or over, payment may be made for a screening barium enema examination (HCPCS G0106) performed after at least 47 months have passed following the month in which the last screening barium enema or screening flexible sigmoidoscopy was performed.  For example, the beneficiary  received a screening barium enema examination as an alternative to a screening flexible sigmoidoscopy in January 1999. Start count beginning February  1999. The beneficiary  is eligible  for another  screening  barium  enema in January  2003.  The screening barium enema must be ordered in writing after a determination that the test is the appropriate screening test. Generally, it is expected that this will be a screening double contrast enema unless the individual is unable to withstand such an exam. This means that in the case of a particular individual, the attending physician must determine that the estimated screening potential for the barium enema is equal to or greater than the screening potential that has been estimated for a screening flexible sigmoidoscopy for the same individual. The screening single contrast  barium  enema  also requires  a written  order  from  the beneficiarys  attending physician in the same manner as described above for the screening double contrast barium enema examination.  Effective for claims with dates of service on or after January 1, 2023, the minimum age for Colorectal  Cancer  Screening;  Barium  Enema;  as an Alternative  to Screening  Sigmoidoscopy is reduced to 45 years and older. CPT 82270* (HCPCS  G0107*)   Colorectal  Cancer Screening;  FOBT,  1-3 Simultaneous Determinations  Effective for services furnished on or after January 1, 1998, screening FOBT (code 82270* (HCPCS  G0107*)  may be paid for beneficiaries  who have  attained age 50, and at  a frequency  of once  every  12 months  (i.e., at least 11 months  have passed  following the month in which  the last covered screening FOBT was performed). This screening FOBT means a guaiac- based test for peroxidase activity, in which the beneficiary completes it by taking samples from two different sites of three consecutive stools. This screening requires a written order from the beneficiarys attending physician, or effective for dates of service on or after January 27, 2014, the beneficiarys attending physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS).  (The term attending physician is defined to mean a doctor of medicine or osteopathy (a s defined in 1861(r)(1) of the Act) who is fully knowledgeable about the beneficiarys medical condition, and who would be responsible for using the results of any examination performed in the overall management of the beneficiarys specific medical problem.)  Effective for services furnished on or after January 1, 2004, payment may be made for an immunoassay- based FOBT  (HCPCS G0328, described below)  as an alternative to the  guaiac-  based  FOBT,  CPT 82270* (HCPCS  G0107*). Medicare will pay for only one covered  FOBT per year, either CPT 82270* (HCPCS G0107*) or HCPCS G0328, but not both. *NOTE : For claims with dates of service prior to January 1, 2007, physicians, suppliers, and providers  report  HCPCS  G0107. Effective  January 1, 2007, HCPCS  G0107 is discontinued and replaced with CPT 82270. Effective for claims with dates of service on or after January 1, 2023, the minimum age for Colorectal  Cancer  Screening;  FOBT,  1-3 Simultaneous  Determinations  is reduced  to 45 years and older.