(Medicare Claims Processing Manual)

HCPCS  G0328  Colorectal  Cancer Screening;  Immunoassay, FOBT,  1-3 Simultaneous Determinations  Effective for services furnished on or after January 1, 2004, screening FOBT, (HCPCS G0328) may be paid as an alternative to CPT 82270* (HCPCS G0107*) for beneficiaries who have attained age 50.  Medicare will pay for a covered FOBT (either CPT 82270* (HCPCS G0107*) or  HCPCS  G0328, but not both)  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).  Screening FOBT, immunoassay, includes the use of a spatula to collect the appropriate number of samples or the use of a special brush for the collection of samples, as determined by the individual manufacturers instructions. This screening requires a written order from the beneficiarys  attending physician, or effective for claims  with dates  of service on or after January 27, 2014, the beneficiarys attending PA, NP, or CNS. (The term attending physician is defined to mean a doctor of medicine or osteopathy (as 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 pro blem.)  Effective  for claims  with dates  of service  on or after January  1, 2023, the minimum age for Colorectal Cancer Screening; Immunoassay, FOBT, 1- 3 Simultaneous Determinations is reduced to 45 years and older.   HCPCS  G0120  Colorectal  Cancer Screening;  Barium  Enema;  as an Alternative to HCPCS G0105, Screening Colonoscopy  Screening  barium enema examinations may  be paid as an alternative to a screening  colonoscopy (HCPCS  G0105)  examination. The same  frequency  parameters  for screening  colonoscopies  (see those codes above) apply. In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination (HCPCS 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 (HCPCS G0120) as an alternative to a screening  colonoscopy (HCPCS  G0105)  in January  2000. Start counts  beginning February  2000. The beneficiary is eligible for another screening barium enema examination (HCPCS 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 colonoscopy, 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  Colonoscopy is reduced to 45 years and older.  HCPCS  G0121  Colorectal  Cancer Screening;  Colonoscopy on Individual  Not Meeting Criteria for High Risk -  Applicable On and After July 1, 2001 Effective for services furnished on or after July 1, 2001, screening colonoscopies (HCPCS G0121)  performed  on individuals  not meeting  the criteria  for being  at high risk  for developing colorectal cancer  (refer to 60.3 of this chapter) may be paid under the following conditions:   At a frequency  of once  every  10 years  (i.e., at  least 119 months  have  passed  following the month in which the last covered HCPCS G0121 screening colonoscopy was performed.)    If the individual would otherwise qualify to have covered a HCPCS G0121 screening colonoscopy based on the above but has had a covered screening flexible sigmoidoscopy (HCPCS  G0104), then he or she may have  covered a HCPCS  G0121 screening  colonoscopy only after at least 47 months have passed following the month in which the last covered HCPCS G0104 flexible sigmoidoscopy was performed. 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 G0121.  HCPCS  G0464 (Replaced  with  CPT  81528)  - Multitarget  sDNA Colorectal  Cancer Screening Test -  CologuardTM Effective for dates of service on or after October 9, 2014, colorectal cancer screening using the CologuardTM multi- target  sDNA test (G0464/81528)  is covered  once  every  3 years  for Medicare beneficiaries that meet all of the following criteria:  Ages  50 to 85 years,    Asymptomatic  (no signs  or symptoms  of colorectal  disease including but not limited  to lower gastrointestinal pain, blood in stool, positive guaiac FOBT or fecal immunochemical test), and,    At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal  cancer,  or, inflammatory  bowel  disease,  including Crohns  Disease and ulcerative colitis; no family history of colorectal cancer adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).  Effective for claims with dates of service on or after October 9, 2014, providers  shall report at least ONE  of the following diagnosis  codes  when  submitting  claims  for the Cologuard multi-  target sDNA test:  Z12.11 Encounter  for screening  for malignant  neoplasm  of colon, OR, Z12.12 Encounter for screening for malignant neoplasm of rectum  NOTE:  Effective  January  1, 2016, HCPCS  G0464 is discontinued and  replaced  with  CPT  81528 Effective for claims with dates of service on or after January 1, 2023, the minimum age for Multitarget sDNA Colorectal  Cancer  Screening  Test - CologuardTM is reduced  to 45 years  and older.   HCPCS  G0327-  Colorectal  Cancer Screening  - Blood -based  Biomarker Tests  Blood- based  DNA testing  detects  molecular  markers  of altered  DNA  that are contained  in the cells shed into the lumen  of the large bowel  by colorectal  cancer  and pre-malignant  colorectal epithelial neoplasia.  Effective for  dates  of service on or  after January  19, 2021, a  blood- based  biomarker  test is covered  as an appropriate  colorectal  cancer  screening  test once  every  3 years  for Medicare beneficiaries when performed in a CLIA -certified laboratory, when ordered by a treating physician and when all of the following requirements are met:  The patient  is:  age 50-85 years,  and,   asymptomatic  (no signs  or symptoms  of colorectal  disease including but not limited  to lower gastrointestinal pain, blood in stool, positive guaiac FOBT or fecal immunochemical test), and,  at average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal  cancer  , or inflammatory  bowel  disease,  including Crohns  Disease  and ulcerative colitis; no family  history of colorectal cancer or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).  The blood- based  biomarker  screening  test must  have  all of the following:   FDA  market  authorization with an indication  for colorectal  cancer  screening;  and,   proven test performance characteristics for a blood -based screening  test with both sensitivity greater than or equal to 74% and specificity greater than or equal to 90% in the detection of colorectal cancer compared to the recognized standard (accepted as colonoscopy at this time),  as minimal threshold levels,  based  on the pivotal  studies  included in the FDA labeling.  Effective for claims  with dates  of service on or after January 19, 2021, providers  shall  report  at least ONE of the following diagnosis codes when submitting claims for the Blood- based Biomarker test HCPCS G0327:  Z12.11 Encounter  for screening  for malignant  neoplasm  of colon, OR, Z12.12 Encounter for screening for malignant neoplasm of rectum  Effective for claims with dates of service on or after January 1, 2023, the minimum age for Colorectal  Cancer  Screening  - Blood- based  Biomarker  Tests  is reduced  to 45 years  and older.   HCPCS  G0122  Colorectal  Cancer Screening;  Barium  Enema  The code  is not  covered  by Medicare.   60.2.1 - Common Working Files (CWF) Edits  (Rev. 10818; Issued: 05- 20-21; Effective: 01 -09-21; Implementation: 10 -04-21) Effective for dates of service January 1, 1998, and later, CWF will edit all colorectal screening claims for age and frequency standards.  The CWF will also edit A/B MAC (A) claims for valid procedure codes (HCPCS G0104, G0105, G0106, CPT 82270* (HCPCS G0107*), G0120, G0121, G0122, G0328, G0327, and CPT 81528 ** (HCPCS G0464**).  The CWF currently edits for valid HCPCS codes for A/B/MACs (B).  (See 60.6 of this chapter for TOBs.)  *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 January 1, 2016, HCPCS G0464 is discontinued and replaced with CPT 81528.   60.2.2 - Ambulatory Surgical Center (ASC) Facility Fee  (Rev. 10818; Issued: 05- 20-21; Effective: 01 -09-21; Implementation: 10 -04-21)  CPT code 45378, which is used to code a diagnostic colonoscopy, is on the list of procedures approved by Medicare for payment of an ambulatory surgical center facility under section 1833 of the Act.  CPT code 45378 is currently assigned to ASC payment group 2.  Code G0105, colorectal cancer; colonoscopy on individuals at high risk, was added to the ASC list effective for services furnished on or after January 1, 1998.  Code G0121, colorectal cancer; colonoscopy on individual not meeting criteria for high risk, was added to the ASC list effective for services furnished on or after July 1, 2001.  Codes G0105 and G0121 are assigned to ASC payment group 2.  The ASC facility service is the same whether the procedure is a screening or a diagnostic colonoscopy.  If during the course of the screening colonoscopy performed at an ASC, 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 rather than code G0105.  Effective for services performed on or after January 1, 2007, a 25% coinsurance payment will apply for the colorectal cancer services (G0105 and G0121).   60.3 - Determining High Risk for Developing Colorectal Cancer  (Rev. 12435, Issued:12- 28-23, Effective:01- 29-24, Implementation:01- 29-24)  A. Characteristics of the High Risk Individual