(Medicare Claims Processing Manual)

Billing and payment for a Digital Rectal Exam (DRE) (G0102) is bundled into the payment for a covered E/M service (CPT codes 99201 -  99456 and 99499) when the two services are furnished to a patient on the same day.  If the DRE is the only service or is pr ovided as part of an otherwise noncovered service, HCPCS code G0102 would be payable separately if all other coverage requirements are met.   50.4 - HCPCS, Revenue, and Type of Service Codes  (Rev. 11902; Issued:03- 16-23; Effective: 04 -17-23; Implementation: 04 -17-23)  The appropriate bill types for billing the A/B MAC (A) on Form CMS -1450 or its electronic equivalent are 12X, 13X, 14X, 22X, 23X, 71X, 73X, 75X, and 85X.  Effective 4/1/06, type of bill 14X is for non- patient laboratory specimens.   The HCPCS code G0102 -  for prostate cancer screening digital rectal examination.    A/B MAC (B) TOS is 1    A/B MAC (A) revenue code is 0770  The HCPCS code G0103 -  for prostate cancer screening PSA tests    A/B MAC (B) TOS is 5     A/B MAC (A) revenue code is 030X   The HCPCS code 0359U  (PROSTATE CANCER), ANALYSIS OF ALL PROSTATE -SPECIFIC ANTIGEN (PSA) STRUCTURAL ISOFORMS BY PHASE SEPARATION AND IMMUNOASSAY, PLASMA, ALGORITHM REPORTS RISK OF CANCER. Effective 01/01/23.    A/B MAC (B) TOS is 5     A/B MAC (A) revenue code is 030X   50.5 - Diagnosis Coding   (Rev. 11021; Issued: 10 -01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  Prostate cancer screening digital rectal examinations and screening Prostate Specific Antigen (PSA) blood tests must be billed using either screening code if ICD-10-CM is applicable, diagnosis code Z12.5 (Encounter for screening for malignant neoplasm of prostate).   50.6 - Calculating Frequency  (Rev. 1, 10- 01-03)  A3-3616.D and E, B3- 4182.4, B3- 4182.5  Calculating Frequency -  To determine the 11- month period, the count starts beginning with the month after the month in which a previous test/procedure was performed.   EXAMPLE: The beneficiary received a screening prostate specific antigen test in January 2002.  Start counts beginning February 2002.  The beneficiary is eligible to receive another screening prostate specific antigen test in January 2003 (the month after 11 months have passed).   Common Working File (CWF) Edits   Beginning October 1, 2000, the following CWF edits were implemented for dates of service January 1, 2000, and later, for prostate cancer screening tests and procedures for the following:    Age;   Frequency;   Sex; and   Valid HCPCS code.   50.7 - MSN Messages (Rev. 1, 10- 01-03)  B3-4182.8.B, A3- 3616.F   If a claim for screening prostate specific antigen test or a screening digital rectal examination is being denied because of the age of the beneficiary, A/B MACs (A) use MSN message 18.13:   This service is not covered for patients under 50 years of age.   The Spanish version of this MSN message should read:   Este servicio no est cubierto hasta despus de que el beneficiario cumpla 50 aos.  A/B MACs (B) use MSN Message 18.19:   This service is not covered until after the patients 50th birthday.  The Spanish version of this MSN message should read:   Este servicio no est cubierto hasta despus de que el beneficiario cumpla 50 aos.  If the claim for screening prostate specific antigen test or screening digital rectal examination is being denied because the time period between the same test or procedure has not passed, A/B MACs (A) and (B) use MSN message 18.14:   Service is being denied because it has not been 12 months since your last test/procedure) of this kind.   The Spanish version of this MSN message should read:   Este servicio est siendo denegado ya que no han transcurrido (12, 24, 48) meses desde el ltimo (examen/procedimiento) de esta clase.   50.8 - Remittance Advice Notices  (Rev. 11021; Issued: 10- 01-21; Effective: 10 -29-21; Implementation: 10 -29-21)  If the claim for a screening prostate antigen test or screening digital rectal examination is being denied because the patient is less than 50 years of age, use the ASC X12 835 with   Claim adjustment reason code; 6 the procedure/revenue code is inconsistent with the patients age, at the line level;  and    Remark code M82 Service not covered when patient is under age 50.   If the claim for a screening prostate specific antigen test or screening digital rectal examination is being denied because the time period between the test/procedure has not passed, A/B MACs (A) and (B) use ASC X12 835 claim adjustment reason code 119, Benefit maximum for this time period has been reached at the line level.   If the claim for a screening prostate antigen test or screening digital rectal examination is being denied due to the absence of ICD -10-CM diagnosis code Z12.5 on the claim, use the ASC X12 835 claim adjustment reason code 167  This (these) diagnosis(es) is (are) not covered.    RARC N386  This decision was based on a National Coverage Determination (NCD).  An NCD provides a coverage determination as to whether a particular item or service is covered.  A copy of this policy is available at www.cms.gov/mcd/search.asp.  If you do not have web access, you may contact the contractor to request a copy of the NCD.    60 - Colorectal Cancer Screening  (Rev. 10818; Issued: 05- 20-21; Effective: 01 -09-21; Implementation: 10 -04-21) See the Medicare Benefit Policy Manual, Chapter 15, and the Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 210.3 for Medicare Part B coverage requirements and effective dates of colorectal cancer screening services.  Effective for services furnished on or after January 1, 1998, payment may be made for colorectal cancer screening for the early detection of cancer.  For screening colonoscopy services (one of the types of services included in this benefit) prior to July 2001, coverage was limited to high- risk individuals.  For services July 1, 2001, and later, screening colonoscopies are covered for individuals not at high risk. The following services are considered colorectal cancer screening services:   Fecal -occult blood test (FOBT),1 -3 simultaneous determinations (guaiac -based);   Flexible sigmoidoscopy;   Colonoscopy; and,  Barium enema   Effective for services on or after January 1, 2004, payment may be made for the following colorectal cancer screening service as an alternative for the guaiac- based FOBT, 1 -3 simultaneous determinations:  FOBT, immunoassay, 1- 3 simultaneous determinations  Effective for services on or after October 9, 2014, payment may be made for colorectal cancer screening using the Cologuard multi- target sDNA test:  HCPCS G0464 (Colorectal cancer screening; stool -based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3). Note:  HCPCS code G0464 expired on December 31, 2015, and has been replaced in the 2016 CLFS with CPT code 81528, Oncology (colorectal) screening, quantitative real -time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result, e ffective January 2, 2016. Effective for services on or after January 19, 2021, payment may be made for colorectal cancer using Blood- based DNA Testing:   Blood- based Biomarker Test, HCPCS G0327, effective July 1, 2021  60.1 - Payment  (Rev. 10818; Issued: 05- 20-21; Effective: 01 -09-21; Implementation: 10 -04-21)  Payment is under the MPFS except as follows:   FOBTs [CPT 82270* (HCPCS G0107*) and HCPCS G0328] are paid under the CLFS except reasonable cost is paid to all non- outpatient prospective payment system (OPPS) hospitals, including Critical Access Hospitals (CAHs), but not Indian Health Service (IHS) hospitals billing on type of bill (TOB) 83X.  IHS hospitals billing on TOB 83X are paid the Ambulatory Surgery Center (ASC) payment amount.  Other IHS hospitals (bil ling on TOB 13X) are paid the Office of Management and Budget (OMB) -approved all -inclusive rate (AIR), or the facility specific per visit amount as applicable.  Deductible and coinsurance do not apply for these tests.  See section A below for payment to Ma ryland waiver hospitals on TOB 13X.  Payment to all hospitals for non- patient laboratory specimens on TOB 14X will be based on the CLFS, including CAHs and Maryland waiver hospitals.    For claims with dates of service on or after January 1, 2015, through December 31, 2015, the Cologuard multi- target sDNA test (HCPCS G0464) is paid under the CLFS.    Note: For claims with dates of service October 9, 2014, thru December 31, 2014, HCPCS code G0464 is paid under local contractor pricing.  For claims with dates of service on or after January 1, 2016, CPT code 81528 replaces G0464 is paid under the CLFS.    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