(Medicare Claims Processing Manual)

 For claims with dates of service on or after January 19, 2021, Blood- based Biomarker test (HCPCS G0327) is paid under the CLFS    Flexible sigmoidoscopy (code G0104) is paid under OPPS for hospital outpatient departments and on a reasonable cost basis for CAHs; or current payment methodologies for hospitals not subject to OPPS.    Colonoscopies (HCPCS G0105 and G0121) and barium enemas (HCPCS G0106 and G0120) are paid under OPPS for hospital outpatient departments and on a reasonable cost basis for CAHs or current payment methodologies for hospitals not subject to OPPS.  Also colonoscopies may be performed in an ASC and when done in an ASC, the ASC rate applies.  T he ASC rate is the same for diagnostic and screening colonoscopies.  The ASC rate is paid to IHS hospitals when the service is billed on TOB 83X. The following screening codes must be paid at rates consistent with the rates of the diagnostic codes indicated.  Coinsurance and deductible apply to diagnostic codes.   HCPCS Screening Code  HCPCS Diagnostic Code  G0104 45330 HCPCS Screening Code  HCPCS Diagnostic Code  G0105 and G0121  45378 G0106 and G0120  74280  A.  Special Payment Instructions for TOB 13X Maryland Waiver Hospitals  For hospitals in Maryland under the jurisdiction of the Health Services Cost Review Commission, screening colorectal services HCPCS G0104, G0105, G0106, 82270* (G0107*), G0120, G0121, G0328, G0464, and 81528 are paid according to the terms of the waiver, that is 94% of submitted charges minus any unmet existing deductible, co- insurance and non- covered charges.  Maryland Hospitals bill TOB 13X for outpatient colorectal cancer screenings.  B.  Special Payment Instructions for Non -Patient Laboratory Specimen (TOB 14X) for All Hospitals  Payment for colorectal cancer screenings (CPT 82270* (HCPCS G0107*), HCPCS G0328, and G0464 (Effective January 1, 2016, HCPCS G0464 is discontinued and replaced with CPT 81528) to a hospital for a non- patient laboratory specimen (TOB 14X), is the lesser of  the actual charge, the fee schedule amount, or the National Limitation Amount (NLA), (including CAHs and Maryland Waiver hospitals).  Part B deductible and coinsurance do not apply.  *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 was discontinued and replaced with CPT 82270.   60.1.1  Deductible and Coinsurance  (Rev. 12299; Issued:10- 12-23; Effective:01 -01-23; Implementation:11 -13-23)  There is no deductible and no coinsurance or copayment for the FOBTs (HCPCS G0107, G0328), flexible  sigmoidoscopies  (G0104), colonoscopies  on individuals  at high risk (HCPCS G0105), or colonoscopies on individuals not meeting criteria of high risk (HCPCS G0121).  Anesthesia services  furnished in conjunction with and in support  of a screening colonoscopy are reported with CPT code 00812 and coinsurance and deductible are waived. When a screening colonoscopy becomes  a diagnostic  colonoscopy, anesthesia services  are reported  with CPT code 00811 and  with  the -PT modifier; and  the deductible  is waived.  Prior to  January 1, 2022, when a screening colonoscopy became a diagnostic, the beneficiary was liable for the full applicable coinsurance. However, Section 122 of Division CC of the Consolidated Appropriations Act  (CAA)  of 2021, Waiving Medicare  Coinsurance  for Certain  Colorectal  Cancer  Screening  Tests, amended section 1833(a) of the Social Security Act to offer a special coinsurance rule for screening flexible sigmoidoscopies and screening colonoscopies, regardless of the code that is billed for the establishment of a diagnosis as a result of the test, or for the removal of tissue or other matter or other procedure, that is furnished in connection with, as a result of, and in the same clinical encounter as the color ectal cancer screening test.  Consequently, the applicable coinsurance in these specific scenarios will be gradually reduced until it is completely waived for dates of service on or after January 1, 2030. Specifically, for dates of service in CY 2023 through CY 2026, when the PT modifier is appended to at least one code on the claim to indicate that a screening colorectal cancer procedure, HCPCS G0104, G0105, or G0121, has become a diagnostic or therapeutic  service, contractors shall continue to waive deductible and shall apply a reduced coinsurance of 15% for all procedure codes that meet the requirements stated above and are performed on t hat date of service and billed on the same claim.  For dates of service in CY 2027 through CY 2029, contractors shall continue to waive deductible and shall apply a reduced coinsurance of 10% for all procedure codes that meet the requirements stated above and are performed on that date of service and bille d on the same claim.  For dates of service on or after January 1, 2030, contractors shall continue to waive deductible and shall waive coinsurance  for all procedure  codes  that meet  the requirements  stated  above and are performed on that date of service and billed on the same claim.   Coinsurance  and deductible  are waived  for moderate sedation  services  (reported  with G0500 or 99153) when furnished in conjunction with and in support of a screening colonoscopy service and when reported with modifier - 33. When a screening colonoscopy becomes a diagnostic colonoscopy, moderate sedation services (G0500 or 99153) are reported with only the - PT modifier; only the deductible is waived. Prior to January 1, 2007 deductible and coinsurance apply to other colorectal procedures (HCPCS  G0106 and G0120). After  January  1, 2007, the deductible  is waived  for those  tests. Coinsurance applies.   Effective for claims with dates of service on and after October 9, 2014, deductible and coinsurance  do not apply to the Cologuard multi -target  sDNA  screening  test (HCPCS  G0464). (Note: Beginning January 1, 2016, CPT code 81528 replaced G0464).   Effective  for claims  with dates  of service on and  after  January  19, 2021, deductible  and coinsurance do not apply to the Blood- based biomarker test (HCPCS G0327).  Effective for claims with dates of service on or after January 1, 2023, colorectal cancer screening tests include a screening colonoscopy (HCPCS codes G0105, G0121) that follows a non-invasive stool - based test (HCPCS codes 82270, G0328 and 81528). This sc enario shall be identified by the furnishing practitioner by including the  KX modifier  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. NOTE: A 25% coinsurance applies for all colorectal cancer screening colonoscopies (HCPCS G0105 and G0121)  performed  in ASCs  and non-OPPS hospitals  effective for services  performed on or after January 1, 2007. The 25% coinsurance was implemented in the OPPS PRICER for OPPS hospitals effective for services performed on or after January 1, 1999. A 25% coinsurance also applies for colorectal cancer screening sigmoidoscopies (HCPCS G0104)  performed  in non-OPPS hospitals  effective for services  performed  on or after January  1, 2007. Beginning January  1, 2008, colorectal  cancer  screening  sigmoidoscopies  (HCPCS  G0104) are payable  in ASCs,  and a 25% coinsurance  applies.  The 25% coinsurance for colorectal  cancer screening  sigmoidoscopies  was implemented  in the OPPS PRICER for OPPS hospitals  effective for services performed on or after January 1, 1999. Effective for claims with dates of service on or after January 1, 2011, coinsurance and deductible  do not apply to screening  colonoscopies, screening  sigmoidoscopies, and other specified colorectal cancer screening services.   60.2 - HCPCS Codes, Frequency Requirements, and Age Requirements  (Rev. 12299; Issued:10 -12-23; Effective:01 -01-23; Implementation:11 -13-23)  Effective  for services  furnished on or after January 1, 1998, the following codes  are used for colorectal cancer screening services:   CPT 82270* (HCPCS  G0107*)  - Colorectal  cancer  screening;  fecal -occult  blood tests,  1-3 simultaneous determinations;  HCPCS  G0104 - Colorectal  cancer  screening;  flexible  sigmoidoscopy;   HCPCS  G0105 -  Colorectal  cancer  screening;  colonoscopy on individual  at high risk;   HCPCS  G0106 - Colorectal  cancer  screening;  barium  enema;  as an alternative to HCPCS G0104, screening sigmoidoscopy;   HCPCS  G0120 - Colorectal  cancer  screening;  barium  enema;  as an alternative to HCPCS G0105, screening colonoscopy.  Effective for services  furnished on or after July 1, 2001, the following codes  are added  for colorectal cancer screening services:   HCPCS  G0121 - Colorectal  cancer  screening;  colonoscopy on individual  not meeting  criteria for high risk.  HCPCS  G0122 - Colorectal  cancer  screening;  barium  enema (non-covered).   Effective  for services  furnished on or after January 1, 2004, the following code  is added  for colorectal cancer screening services as an alternative to CPT 82270* (HCPCS G0107*):   HCPCS  G0328 - Colorectal  cancer  screening;  immunoassay, fecal -occult  blood test, 1-3 simultaneous determinations.   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).