evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
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)
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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   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 adenomatous polyps;    A personal history of colorectal cancer; or
(Medicare Claims Processing Manual)
 A family history of hereditary nonpolyposis colorectal cancer;    A personal history of adenomatous polyps;    A personal history of colorectal cancer; or    Inflammatory bowel disease, including Crohns Disease, and ulcerative colitis.    B. Partial List of ICD -10-CM Codes Indicating High Risk   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 considered high risk at the medical director s discretion.    Partial List of diagnosis codes indicating high risk: only applicable to G0105 and G0120 (high risk colorectal cancer screening)
(Medicare Claims Processing Manual)
C18.0  Malignant neoplasm of cecum  C18.2  Malignant neoplasm of ascending colon  C18.3  Malignant neoplasm of hepatic flexure  C18.4  Malignant neoplasm of transverse colon  C18.5  Malignant neoplasm of splenic flexure  C18.6  Malignant neoplasm of descending colon  C18.7  Malignant neoplasm of sigmoid colon C18.8  Malignant neoplasm of overlapping sites of colon  C19   Malignant neoplasm of rectosigmoid junction C20   Malignant neoplasm of rectum  C21.0  Malignant neoplasm of anus, unspecified  C21.1  Malignant neoplasm of anal canal  C21.2  Malignant neoplasm of cloacogenic zone  C21.8  Malignant neoplasm of overlapping sites of rectum, anus and anal canal  C49.A3  Gastrointestinal stromal tumor of small intestine  C49.A4  Gastrointestinal stromal tumor of large intestine  C49.A5  Gastrointestinal stromal tumor of rectum  C78.5  Secondary malignant neoplasm of large intestine and rectum  C7A.021  Malignant carcinoid tumor of the cecum  C7A.022  Malignant carcinoid tumor of the ascending colon  C7A.023  Malignant carcinoid tumor of the transverse colon C7A.024  Malignant carcinoid tumor of the descending colon C7A.025  Malignant carcinoid tumor of the sigmoid colon C7A.026  Malignant carcinoid tumor of the rectum  D01.0  Carcinoma in situ of colon D01.1  Carcinoma in situ of rectosigmoid junction  D01.2  Carcinoma in situ of rectum  D01.3  Carcinoma in situ of anus and anal canal  D12.0  Benign neoplasm of cecum  D12.2  Benign neoplasm of ascending colon D12.3  Benign neoplasm of transverse colon  D12.4  Benign neoplasm of descending colon D12.5  Benign neoplasm of sigmoid colon D12.7  Benign
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neoplasm of ascending colon D12.3  Benign neoplasm of transverse colon  D12.4  Benign neoplasm of descending colon D12.5  Benign neoplasm of sigmoid colon D12.7  Benign neoplasm of rectosigmoid junction  D12.8  Benign neoplasm of rectum  D12.9  Benign neoplasm of anus and anal canal  D37.4  Neoplasm of uncertain behavior of colon D37.5  Neoplasm of uncertain behavior of rectum  D37.9  Neoplasm of uncertain behavior of digestive organ, unspecified  D3A.021  Benign carcinoid tumor of the cecum  D3A.022  Benign carcinoid tumor of the ascending colon  D3A.023  Benign carcinoid tumor of the transverse colon  D3A.024  Benign carcinoid tumor of the descending colon  D3A.025  Benign carcinoid tumor of the sigmoid colon D3A.026  Benign carcinoid tumor of the rectum  D3A.029  Benign carcinoid tumor of the large intestine, unspecified portion  K50.00  Crohn's disease of small intestine without complications  K50.011  Crohn's disease of small intestine with rectal bleeding  K50.012  Crohn's disease of small intestine with intestinal obstruction  K50.013  Crohn's disease of small intestine with fistula  K50.014  Crohn's disease of small intestine with abscess  K50.018  Crohn's disease of small intestine with other complication  K50.019  Crohn's disease of small intestine with unspecified complications  K50.10  Crohn's disease of large intestine without complications  K50.111  Crohn's disease of large intestine with rectal bleeding K50.112  Crohn's disease of large intestine with intestinal obstruction K50.113  Crohn's disease of large intestine with fistula  K50.114  Crohn's disease of large intestine with abscess  K50.118  Crohn's disease of large intestine with other complication K50.119  Crohn's disease
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fistula  K50.114  Crohn's disease of large intestine with abscess  K50.118  Crohn's disease of large intestine with other complication K50.119  Crohn's disease of large intestine with unspecified complications  K50.80  Crohn's disease of both small and large intestine without complications  K50.811  Crohn's disease of both small and large intestine with rectal bleeding  K50.812  Crohn's disease of both small and large intestine with intestinal
(Medicare Claims Processing Manual)
obstruction K50.813  Crohn's disease of both small and large intestine with fistula  K50.814  Crohn's disease of both small and large intestine with abscess  K50.818  Crohn's disease of both small and large intestine with other complication K50.819  Crohn's disease of both small and large intestine with unspecified complications  K50.90  Crohn's disease, unspecified, without complications  K50.911  Crohn's disease, unspecified, with rectal bleeding K50.912  Crohn's disease, unspecified, with intestinal obstruction K50.913  Crohn's disease, unspecified, with fistula  K50.914  Crohn's disease, unspecified, with abscess  K50.918  Crohn's disease, unspecified, with other complication K50.919  Crohn's disease, unspecified, with unspecified complications  K51.00  Ulcerative (chronic) pancolitis without complications  K51.011  Ulcerative (chronic) pancolitis with rectal bleeding  K51.012  Ulcerative (chronic) pancolitis with intestinal obstruction  K51.013  Ulcerative (chronic) pancolitis with fistula  K51.014  Ulcerative (chronic) pancolitis with abscess  K51.018  Ulcerative (chronic) pancolitis with other complication  K51.019  Ulcerative (chronic) pancolitis with unspecified complications  K51.20  Ulcerative (chronic) proctitis without complications  K51.211  Ulcerative (chronic) proctitis with rectal bleeding  K51.212  Ulcerative (chronic) proctitis with intestinal obstruction  K51.213  Ulcerative (chronic) proctitis with fistula  K51.214  Ulcerative (chronic) proctitis with abscess  K51.218  Ulcerative (chronic) proctitis with other complication  K51.219  Ulcerative (chronic) proctitis with unspecified complications  K51.30  Ulcerative (chronic) rectosigmoiditis without complications  K51.311  Ulcerative (chronic) rectosigmoiditis with rectal bleeding  K51.312  Ulcerative (chronic)
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unspecified complications  K51.30  Ulcerative (chronic) rectosigmoiditis without complications  K51.311  Ulcerative (chronic) rectosigmoiditis with rectal bleeding  K51.312  Ulcerative (chronic) rectosigmoiditis with intestinal obstruction  K51.313  Ulcerative (chronic) rectosigmoiditis with fistula  K51.314  Ulcerative (chronic) rectosigmoiditis with abscess  K51.318  Ulcerative (chronic) rectosigmoiditis with other complication  K51.319  Ulcerative (chronic) rectosigmoiditis with unspecified complications  K51.40  Inflammatory polyps of colon without complications  K51.411  Inflammatory polyps of colon with rectal bleeding  K51.412  Inflammatory polyps of colon with intestinal obstruction K51.413  Inflammatory polyps of colon with fistula  K51.414  Inflammatory polyps of colon with abscess  K51.418  Inflammatory polyps of colon with other complication K51.419  Inflammatory polyps of colon with unspecified complications  K51.50  Left sided colitis without complications  K51.511  Left sided colitis with rectal bleeding  K51.512  Left sided colitis with intestinal obstruction  K51.513  Left sided colitis with fistula  K51.514  Left sided colitis with abscess  K51.518  Left sided colitis with other complication  K51.519  Left sided colitis with unspecified complications  K51.80  Other ulcerative colitis without complications  K51.811  Other ulcerative colitis with rectal bleeding  K51.812  Other ulcerative colitis with intestinal obstruction  K51.813  Other ulcerative colitis with fistula  K51.814  Other ulcerative colitis with abscess  K51.818  Other ulcerative colitis with other complication  K51.819  Other ulcerative colitis with unspecified complications  K51.90  Ulcerative colitis, unspecified, without complications  K51.911  Ulcerative colitis, unspecified with rectal bleeding  K51.912  Ulcerative colitis, unspecified with intestinal obstruction  K51.913  Ulcerative colitis, unspecified with fistula  K51.914  Ulcerative colitis, unspecified with abscess  K51.918  Ulcerative
(Medicare Claims Processing Manual)
Ulcerative colitis, unspecified with intestinal obstruction  K51.913  Ulcerative colitis, unspecified with fistula  K51.914  Ulcerative colitis, unspecified with abscess  K51.918  Ulcerative colitis, unspecified with other complication  K51.919  Ulcerative colitis, unspecified with unspecified complications  K52.1  Toxic gastroenteritis and colitis  K52.89  Other specified non- infective gastroenteritis and colitis  K52.9  Non-infective gastroenteritis and colitis, unspecified  K57.20  Diverticulitis of large intestine with perforation and abscess without bleeding  K57.21  Diverticulitis of large intestine with perforation and abscess with bleeding  K57.30  Diverticulosis of large intestine without perforation or abscess without bleeding K57.31  Diverticulosis of large intestine without perforation or abscess with bleeding  K57.32  Diverticulitis of large intestine without perforation or abscess without bleeding  K57.33  Diverticulitis of large intestine without perforation or abscess with bleeding  K57.40  Diverticulitis of both small and large intestine with perforation and abscess
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without bleeding  K57.41  Diverticulitis of both small and large intestine with perforation and abscess with                          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
(Medicare Claims Processing Manual)
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.)
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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:
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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.
(Medicare Claims Processing Manual)
60.7 - Medicare Summary Notice (MSN) Messages (Rev. 12299; Issued:10 -12-23; Effective:01 -01-23; Implementation:11 -13-23)
(Medicare Claims Processing Manual)
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.
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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.
(Medicare Claims Processing Manual)
*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