(Medicare Claims Processing Manual)

bleeding K57.50  Diverticulosis of both small and large intestine without perforation or abscess                           without bleeding  K57.51  Diverticulosis of both small and large intestine without perforation or abscess                          with bleeding K57.52  Diverticulitis of both small and large intestine without perforation or abscess                          without bleeding  K57.53  Diverticulitis of both small and large intestine without perforation or abscess with                           bleeding K57.80  Diverticulitis of intestine, part unspecified, with perforation and abscess without                           bleeding K57.81  Diverticulitis of intestine, part unspecified, with perforation and abscess with                          bleeding K57.90  Diverticulosis of intestine, part unspecified, without perforation or abscess                          without bleeding  K57.91  Diverticulosis of intestine, part unspecified, without perforation or abscess with                          bleeding K57.92  Diverticulitis of intestine, part unspecified, without perforation or abscess without                          bleeding K57.93  Diverticulitis of intestine, part unspecified, without perforation or abscess with                          bleeding K62.0  Anal polyp K62.1  Rectal polyp  K62.6  Ulcer of anus and rectum  K63.3  Ulcer of intestine  K63.5  Polyp of colon Z12.10  Encounter for screening for malignant neoplasm of intestinal tract, unspecified Z12.11  Encounter for screening for malignant neoplasm of colon Z12.12  Encounter for screening for malignant neoplasm of rectum  Z15.09  Genetic susceptibility to other malignant neoplasm Z80.0  Family history of malignant neoplasm of digestive organs  Z83.710          Family history of adenomatous and serrated polyps  Z83.711          Family history of hyperplastic colon polyps  Z83.718          Other family history of colon polyps  Z83.719          Family history of colon polyps, unspecified  Z85.038 Personal history of other malignant neoplasm of large intestine  Z85.048  Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus Z86.004  Personal history of in- situ neoplasm of other and unspecified digestive organs  Z86.010  Personal history of colonic polyps   Applicable to G0464/81528: colorectal cancer screening; stool -based DNA and fecal occult hemoglobin (e.g., kras, ndrg4 and bmp3), as well as G0327: colorectal cancer screening; blood-based biomarker -  only 1 diagnosis required    Z12.12 Encounter for screening for malignant neoplasm of rectum  Z12.11 Encounter for screening for malignant neoplasm of colon  60.4 - Determining Frequency Standards  (Rev. 3436, Issued: 12- 30-15, Effective: 10 -09-14, Implementation: 09- 08-15 for non -shared MAC edits; 01 -04-16 - For all shared system changes.)   To determine the 11- , 23-, 35-, 47-, and 119 -month periods, start counts beginning with the month after the month in which a previous test/procedure was performed.   EXAMPLE:  The beneficiary received an FOBT in January 2000.  Start count beginning with February 2000.  The beneficiary is eligible to receive another blood test in January 2001 (the month after 11 full months have passed).   60.5 - Noncovered Services  (Rev. 10818; Issued: 05- 20-21; Effective: 01 -09-21; Implementation: 10 -04-21)  The following non- covered HCPCS codes are used to allow claims to be billed and denied for beneficiaries who need a Medicare denial for other insurance purposes for the dates of service indicated:   A. From January 1, 1998,  through June 30, 2001, Inclusive   Code G0121 (colorectal cancer; colonoscopy on an individual not meeting criteria for high risk) should be used when this procedure is performed on a beneficiary who does not  meet the criteria for high risk.  This service should be denied as non- covered because it fails to meet the requirements of the benefit for these dates of service.  The beneficiary is liable for payment.  Note that this code is a covered service for dates  of service on or after July 1, 2001.  B. On or After January 1, 1998  Code G0122 (colorectal cancer; barium enema) should be used when a screening barium enema is performed not  as an alternative to either a screening colonoscopy (code G0105) or a screening flexible sigmoidoscopy (code G0104).  This service should be denied as non- covered because it fails to meet the requirements of the benefit.  The beneficiary is liable for pay ment.   60.6 - Billing Requirements for Claims Submitted to A/B MACs (A)  (Rev. 10818; Issued: 05- 20-21; Effective: 01 -09-21; Implementation: 10 -04-21) Follow the general bill review instructions in chapter 25.  Hospitals use the ASC X12 837 institutional claim format to bill the A/B MAC (A) or the hardcopy Form CMS -1450 (UB -04).  Hospitals bill revenue codes and HCPCS codes as follows:   Screening Tests/Procedures  Revenue Codes  HCPCS Codes  TOBs  FOBT  030X  82270*** (G0107***), G0328 12X, 13X, 14X**, 22X, 23X, 83X, 85X  Barium enema  032X  G0106, G0120, G0122 12X, 13X, 22X, 23X, 85X**** Flexible Sigmoidoscopy * G0104 12X, 13X, 22X, 23X, 85X**** Screening Tests/Procedures  Revenue Codes  HCPCS Codes  TOBs  Colonoscopy- high risk * G0105, G0121 12X, 13X, 22X, 23X, 85X**** Multitarget sDNA -  CologuardTM  030X  (G0464*****), 81528***** 13X, 14X** 85X Blood- based Biomarker  030X  (G0327)  13X, 14X** 85X  * The appropriate revenue code when reporting any other surgical procedure. ** 14X is only applicable for non- patient laboratory specimens.  *** For claims with dates of service prior to January 1, 2007, physicians, suppliers, and providers report HCPCS code G0107.  Effective January 1, 2007, HCPCS G0107, was discontinued and replaced with CPT 82270. **** CAHs that elect Method II bill revenue code 096X, 097X, and/or 098X for professional services and 075X (or other appropriate revenue code) for the technical or facility component. ***** Effective January 1, 2016, HCPCS G0464 is discontinued and replaced with CPT 81528 Special Billing Instructions for Hospital Inpatients  When these tests/procedures are provided to inpatients of a hospital or when Part A benefits have been exhausted, they are covered under this benefit.  However, the provider bills on TOB 12X using the discharge date of the hospital stay to avoid editing in CWF as a result of the hospital bundling rules.  60.7 - Medicare Summary Notice (MSN) Messages (Rev. 12299; Issued:10 -12-23; Effective:01 -01-23; Implementation:11 -13-23)   The following Medicare Summary  Notice  (MSN) messages  are used (See Chapter  21 for the Spanish versions of these messages):  A. If a claim  for a screening FOBT,  a screening  flexible  sigmoidoscopy, or a barium  enema is being denied because of the age of the beneficiary, use:  18.29 -  This service is  not covered  for people  under  45 years  of age. Spanish Version - Este servicio  no est cubierto  para las  personas  menores  de 45 aos.  B. If the claim for a screening FOBT, a screening colonoscopy, a screening flexible sigmoidoscopy, or a barium  enema is being denied because  the time period  between  the same test or procedure has not passed, use:  18.14 - Service is being denied  because it has not been  (12, 24, 48, 120) months  since your  last (test/procedure) of this kind. C. If the claim  is being denied  for a screening  colonoscopy or a barium  enema because the beneficiary is not at a high risk, use:  18.15 - Medicare  covers  this procedure  only for people  considered to be at a high risk  for colorectal cancer.  D. If the  claim is being  denied because  payment has already  been made for a  screening  FOBT (CPT  82270* (HCPCS  G0107*)  or HCPCS  G0328), flexible  sigmoidoscopy (HCPCS  G0104), screening colonoscopy (HCPCS G0105), or a screening barium enema (HCPCS G0106 or G0120), use:  18.16 - This service  is denied  because  payment  has already  been  made for a similar  procedure within a set timeframe.  NOTE:  MSN message 18.16 should only be used when a certain screening procedure is performed  as an alternative to another  screening  procedure.  For example:  If the claims  history indicates  a payment  has been  made for HCPCS  G0120 and an incoming claim  is submitted  for HCPCS G0105 within 24 months, the incoming claim should be denied.  E. If the claim  is being denied  for a non-covered  screening  procedure  code such as HCPCS G0122, use:  16.10 -  Medicare does not pay for this item or  service.  If an invalid  procedure  code  is reported, the contractor  will return  the claim  as unprocessable  to the provider under current procedures.  *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. F. If denying claims for Cologuard multi- target sDNA screening test (HCPCS G0464 -  Effective January  1, 2016, HCPCS G0464 has been discontinued and replaced with CPT  81528) or Blood- based Biomarker test (HCPCS G0327) when furnished more than once in a 3- year period [at least 2 years and  11 full months  (35 months  total)  must  elapse from  the date of the last screening], use:  15.19:  We used a Local  Coverage  Determination  (LCD) to decide coverage for your  claim.  To appeal, get a copy of the LCD at www.cms.gov/medicare -coverage- database (use the MSN Billing Code for the CPT/HCPCS Code) and send with information from your doctor."  Spanish Version -  Usamos una Determinacin de Cobertura Local (LCD) para decidir la cobertura  de su reclamo.  Para apelar,  obtenga  una copia  del LCD  en www.cms.gov/medicare - coverage- database (use el cdigo de facturacin de MSN para el cdigo "CPT/HCPCS") y envela con la informacin de su mdico.  15.20 - The following policies NCD  210.3 were  used when we  made this decision  Spanish Version   Las  siguientes  polticas  NCD210.3 fueron  utilizadas  cuando  se tom  esta decisin