(Medicare Benefit Policy Manual)

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  should be billed and paid rather than code G0104.   Effective January 1, 2023, the minimum age for Screening Flexible Sigmoidoscopies is reduced to 45 years and older. For complete claims processing information, refer to Pub 100- 04, Medicare Claims Processing Manual, chapter 18, section 60.   C. Screening  Colonoscopies  for Beneficiaries  at High  Risk  of Developing  Colorectal Cancer (Code G0105)   The A/B MAC  (B) must  pay for screening  colonoscopies  (code  G0105)  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  G0105 screening  colonoscopy was performed).  Refer to 280.2.3 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 should be billed and paid rather than code G0105.   Effective January 1, 2023, colorectal cancer screening tests include a follow -on Screening Colonoscopy for Beneficiaries at High Risk of Developing Colorectal Cancer after a Medicare covered non -invasive stool -based colorectal cancer screening test returns  a positive result. Non- invasive stool -based colorectal cancer screening tests include:    Screening Guaiac- based Fecal Occult Blood Test (gFOBT) (82270)   Screening Immunoassay -based Fecal Occult Blood Test (iFOBT) (G0328)   Screening The Cologuard  Multi- target Stool DNA (sDNA) Test (81528)   The frequency limitations described for Screening Colonoscopies for Beneficiaries at High Risk of Developing Colorectal Cancer in this section shall not apply in the instance of a follow -on Screening Colonoscopy for Beneficiaries at High Risk of Developing Colorectal Cancer after a Medicare covered non -invasive stool -based colorectal cancer screening test returns a positive result. For complete claims processing information, refer to Pub 100- 04, Medicare Claims Processing Manual, chapter 18, section 60.   D. Screening  Colonoscopies  Performed  on Individuals  Not Meeting  the Criteria  for Being at High -Risk for Developing Colorectal Cancer (Code G0121)   Effective  for services  furnished on or after July 1, 2001, screening  colonoscopies  (code G0121) are covered when performed under the following conditions:   1. On individuals  not meeting  the criteria  for being at high risk for developing colorectal cancer (refer to 280.2.3);   2. At a frequency of once every 10 years (i.e., at least 119 months have passed following the month in which  the last covered  G0121 screening  colonoscopy was performed); and   3. If the individual would otherwise qualify to have covered a G0121 screening colonoscopy based on the  above  (see 280.2.2.D.1 and 2)  but has had a covered screening flexible sigmoidoscopy (code G0104), then the individual may have a covered G0121 screening colonoscopy only after at least 47 months have passed following the month in which  the last covered  G0104 flexible  sigmoidoscopy was performed.   NOTE:  I f 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 should be billed and paid rather than code G0121.   Effective January 1, 2023, colorectal cancer screening tests include a follow -on Screening Colonoscopy Performed on Individuals Not Meeting the Criteria for Being at High -Risk for Developing Colorectal Cancer after a Medicare covered non -invasive stool -based colorectal cancer screening test returns a positive result. Non-invasive stool -based colorectal cancer screening tests include:    Screening Guaiac- based Fecal Occult Blood Test (gFOBT) (82270)   Screening Immunoassay -based Fecal Occult Blood Test (iFOBT) (G0328)   Screening The Cologuard  Multi- target Stool DNA (sDNA) Test (81528)   The frequency limitations described for Colonoscopies Performed on Individuals Not Meeting the Criteria for Being at High -Risk for Developing Colorectal Cancer in this section shall not apply in the instance of a follow -on Screening Colonoscopy Performed o n Individuals Not Meeting the Criteria for Being at High- Risk for Developing Colorectal Cancer after a Medicare covered non -invasive stool -based colorectal cancer screening test returns a positive result. For complete claims processing information, refer t o Pub 100- 04, Medicare Claims Processing Manual, chapter 18, section 60.   E. Screening  Barium  Enema  Examinations  (codes  G0106 and G0120)   Screening  barium  enema  examinations  are covered  as an alternative  to either  a screening sigmoidoscopy (code G0104) or a screening colonoscopy (code G0105) examination.  The same frequency  parameters  for screening  sigmoidoscopies  and screening colonoscopies above apply.   In the case of an individual aged 50 or over, payment may be made for a screening barium  enema examination  (code  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. The count starts beginning February 1999. The beneficiary  is eligible for another screening barium enema in January 2003.  In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination (code G0120) performed after at least 23 months  have  passed  following the month in which  the last screening  barium  enema or the last screening colonoscopy was performed. For example, a beneficiary at high risk for developing colorectal cancer received a screening barium enema examination (code G0120) as an alternative to a screening colonoscopy (code G0105) in January  2000. The count starts beginning February 2000. The beneficiary is eligible for another screening barium enema examination (code G0120) in January 2002.   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, or for a screening colonoscopy, as appropriate, 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 January 1, 2023, the minimum age for Screening Barium Enema Examinations is reduced to 45 years and older. For complete claims processing information, refer to Pub 100- 04, Medicare Claims Processing Manual, chapter 18, section 60.      280.2.3 - Determining Whether or Not the Beneficiary is at High Risk for Developing Colorectal Cancer  (Rev. 194, Issued: 09- 03-14, Effective: Upon Implementation of ICD -10, Implementation: Upon Implementation of ICD -10)  A.  Characteristics of the High Risk Individual   An individual at high risk for developing colorectal cancer has one or more of the following:   A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;  A family history of familial adenomatous polyposis;  A family history of hereditary nonpolyposis colorectal cancer;  A personal history of colorectal cancer;  A personal history of adenomatous polyps;  Inflammatory bowel disease, including Crohns Disease, and ulcerative colitis.   B.  Partial List of ICD -9-CM Codes Indicating High Risk (for Services before Implementation of ICD -10)  Listed below are some examples of diagnoses that meet the high risk criteria for colorectal cancer.  This is not an all -inclusive list.  There may be more instances of conditions which may be coded and could be at the medical directors discretion.   Personal History   o V10.05 -  Personal history of malignant neoplasm of large intestine  o V10.06 -  Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus    Chronic Digestive Disease Condition   o 555.0 -  Regional enteritis of small intestine  o 555.1 -  Regional enteritis of large intestine  o 555.2 -  Regional enteritis of small intestine with large intestine  o 555.9 -  Regional enteritis of unspecified site  o 556.0 -  Ulcerative (chronic) enterocolitis  o 556.1 -  Ulcerative (chronic) ileocolitis  o 556.2 -  Ulcerative (chronic) proctitis  o 556.3 -  Ulcerative (chronic) proctosigmoiditis  o 556.8 -  Other ulcerative colitis  o 556.9 -  Ulcerative colitis, unspecified (nonspecific PDX on the MCE)    Inflammatory Bowel   o 558.2 -  Toxic gastroenteritis and colitis  o 558.9 -  Other and unspecified noninfectious gastroenteritis and colitis   C.  Partial List of ICD -10-CM Codes Indicating High Risk (for Services after Implementation of ICD -10)