Preventive Services

Preventive Services Guide

Colorectal Cancer Screening

Screenings are performed to diagnose colorectal cancer or to determine a beneficiary’s risk for developing colorectal cancer. Colorectal cancer screening may consist of several different screening services to test for polyps or colorectal cancer.

Table of Contents

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High-Risk Factors Associated With Colorectal Cancer

  • Close relative (sibling, parent or child) who has had colorectal cancer or adenomatous polyp
  • Family history of familial adenomatous polyposis
  • Family history of hereditary nonpolyposis colorectal cancer
  • Personal history of adenomatous polyps
  • Personal history of colorectal cancer
  • Inflammatory bowel disease, including Crohn’s disease and ulcerative colitis

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Coverage Criteria and Frequency Limits

Covered Colorectal Screening Tests/Procedures

  • Fecal occult blood test
    • Beneficiaries 45 and older: one test each year
      • At least 11 full months must have passed following the month since the last covered test
    • Written order is required
    • Payment may be made for immunoassay-based fecal occult blood test as an alternative to guaiac based fecal occult blood test
    • Copayment/coinsurance/deductible are waived
  • Cologuard Multitarget sDNA Test and Blood Based Biomarker Tests
    • Beneficiaries are covered once every three years when all of the following criteria is met
      • Age 45 to 85 years
      • Asymptomatic
      • At average risk of developing colorectal cancer once every three years
    • Use ICD-10 codes Z12.11 and Z12.12
    • Coinsurance/deductible waived

      Effective 1/1/2023, if the patient initially has a noninvasive stool-based screening test (FOBT or MT-sDNA test) and gets a positive result, we will also cover a follow up colonoscopy as a screening test. The patient pays nothing for the screening test if their doctor or other qualified health care provider accepts assignment. The frequency limitations described for screening colonoscopies don’t apply in this scenario.

      Attach the KX modifier to a screening colonoscopy code to indicate such service was performed as a follow up screening after a positive result from a stool-based test.
       
  • Flexible sigmoidoscopy
    • Beneficiaries age 45 and older and at normal risk: once every four years
      • At least 47 full months must have passed since last covered sigmoidoscopy
    • If beneficiary has had screening colonoscopy within preceding ten years, then next screening flexible sigmoidoscopy will be covered only after at least 119 full months have passed since last covered colonoscopy
    • Copayment/coinsurance/deductible are waived
    • Beneficiaries age 45 and older and at high risk: once every four years
      • At least 47 full months must have passed since last covered sigmoidoscopy
    • Copayment/coinsurance/deductible are waived
  •  
  • Colonoscopy
    • Beneficiaries age 45 and older and others at high risk regardless of age
      • High risk covered once every two years
      • Normal risk covered once every ten years
    • If a screening flexible sigmoidoscopy has been performed, 47 months must have passed to be eligible for colonoscopy
    • Copayment/coinsurance/deductible are waived
      • Copayment/coinsurance/deductible are waived (append modifier 33 for services that qualify for a waiver)
      • For separately reported services specifically identified as preventive, the modifier should not be used
  •  
  • Barium enema (as an alternative to a screening flexible sigmoidoscopy or screening colonoscopy)
    • High risk covered every two years
    • Age 45 or older and not at high risk are covered once every four years
    • Copayment/coinsurance applies; deductible waived

Note: The minimum age for colorectal cancer screening was lowered from age 50 to 45 for certain tests as of 1/1/2023.

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Anesthesia Services Effective 1/1/2018

  • When a screening colonoscopy becomes a diagnostic colonoscopy, anesthesia services are reported with CPT code 00811 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified) and with the PT modifier; only the deductible is waived.
  • Anesthesia services furnished in conjunction with and in support of a screening colonoscopy are reported with CPT code 00812 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy); deductible and coinsurance waived.
  • Coinsurance and deductible are waived for moderate sedation (reported with G0500 or 99153) when furnished in conjunction with and in support of a screening colonoscopy service when reported with modifier 33.
  • When a screening colonoscopy becomes diagnostic, moderate sedation services (G0500 or 99153) are reported with only the PT modifier; the deductible is waived.

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Incomplete Colonoscopy

  • When covered colonoscopy attempted but not completed
    • Append modifier 53 to indicate procedure discontinued
  • When covered colonoscopy next attempted and completed
    • Colonoscopy will be paid according to payment methodology for procedure for both screening and diagnostic colonoscopies
  • Coverage conditions must be met and frequency standards will be applied by CWF

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Diagnostic Colorectal Tests

  • Part B deductible waived for colorectal cancer screening tests that become diagnostic, appropriate diagnostic procedure code should be billed/paid rather than screening code
  • For dates of service from 1/1/2023 – 12/31/2023, coinsurance is reduced to 15%. CY2027 through CY2029, coinsurance is reduced to 10%. CY2030, coinsurance is 0%.
    • Surgical procedures CPT code range 10000–69999 furnished same date/encounter
    • Colonoscopy, flexible sigmoidoscopy, or barium enema
    • Append modifier PT to surgical procedure

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HCPCS/CPT Coding

  • G0104: Flexible sigmoidoscopy
  • G0105: Colonoscopy on individual at high risk
  • G0106: Barium enema – alternative to G0104
  • G0120: Barium enema – alternative to G0105
  • G0121: Colonoscopy on individual not at high risk
  • G0122: Barium enema (noncovered)
    • Use when screening barium enema is not performed as an alternative to G0104 or G0105
  • G0327: Colorectal cancer screening; blood-based biomarker
  • G0328: Fecal occult blood test, immunoassay, 1–3 simultaneous
  • 81528: Cologuard™ test
  • 82270: Fecal occult blood test, 1–3 simultaneous determinations

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Diagnosis Coding

Find the most current list of ICD-10 codes in the 210.3 Colorectal Cancer Screening coding file.

Note: Additional ICD-10 codes may apply. Find individual change requests and specific ICD-10-CM services does we cover on the CMS ICD-10 webpage. Find your MACs website for more information.

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Reimbursement

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Nonparticipating Providers

  • Nonparticipating reduction applies
  • Limiting charge provision applies

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Common Claim Denials

  • This service is not covered for patients under 45 years of age.
  • Service is being denied because it has not been (12, 24, 48, 120) months since your last (test/procedure) of this kind.
  • Medicare covers this procedure only for patients considered to be at a high risk for colorectal cancer.
  • This service is denied because payment has already been made for a similar procedure within a set timeframe.
  • Medicare does not pay for this item or service.

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Related Content

Revised 4/17/2024