Screening Fecal-Occult Blood Tests (FOBT) (Codes G0107 & G0328)
Effective for services furnished on or after January 1, 2004, one screening FOBT (code G0107 or G0328) is covered for beneficiaries who have attained age 50, at a frequency of once every 12 months (i.e., at least 11 months have passed following the month in which the last covered screening FOBT was done). Screening FOBT means: (1) a guaiac-based test for peroxidase activity in which the beneficiary completes it by taking samples from two different sites of three consecutive stools or, (2) a immunoassay (or immunochemical) test for antibody activity in which the beneficiary completes the test by taking the appropriate number of samples according to the specific manufacturer’s instructions.
This expanded coverage is in accordance with revised regulations at 42 CFR 410.37(a)(2) that includes “ other tests determined by the Secretary through a national coverage determination.” This screening requires a written order from the beneficiary’s attending physician. (The term “attending physician” is defined to mean a doctor of medicine or osteopathy (as defined in §1861(r)(1) of the Act) who is fully knowledgeable about the beneficiary’s medical condition, and who would be responsible for using the results of any examination performed in the overall management of the beneficiary’s specific medical problem.)
Screening Flexible Sigmoidoscopies (code G0104)
For claims with dates of service on or after January 1, 2002, carriers pay for screening flexible sigmoidoscopies (Code G0104) for beneficiaries who have attained age 50 when these services were performed by a doctor of medicine or osteopathy, or by a physician assistant, nurse practitioner, or clinical nurse specialist (as defined in §1861(aa)(5) of the Act and in the Code of Federal Regulations at 42 CFR 410.74, 410.75, and 410.76) at the frequencies noted below. For claims with dates of service prior to January 1, 2002, pay for these services under the conditions noted only when they are performed by a doctor of medicine or osteopathy.
For services furnished from January 1, 1998, through June 30, 2001, inclusive Once every 48 months (i.e., at least 47 months have passed following the month in which the last covered screening flexible sigmoidoscopy was done).
For services furnished on or after July 1, 2001
Once every 48 months as calculated above unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer (refer to §280.2.3) and the beneficiary has had a screening colonoscopy (code G0121) within the preceding 10 years. If such a beneficiary has had a screening colonoscopy within the preceding 10 years, then he or she can have covered a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that he/she received the screening colonoscopy (code G0121).
NOTE: If during the course of a screening flexible sigmoidoscopy a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a flexible sigmoidoscopy with biopsy or removal should be billed and paid rather than code G0104.
Colorectal Cancer 82270, G0104, G0120 & G0328
Primarily affecting men and women ages 50 and older, colorectal cancer is the third leading cause of cancer deaths in the United States. The risk of developing the disease increases with age.1 Patients with colorectal cancer rarely display any symptoms, and the cancer can progress unnoticed and untreated until it becomes fatal. The most common symptom of colorectal cancer is bleeding from the rectum. Other common symptoms include cramps, abdominal pain, intestinal obstruction, or a change in bowel habits.
Colorectal cancer is largely preventable through screening, which can find pre-cancerous polyps (growths in the colon) that can be removed before they develop into cancer. Screening can also detect cancer early when it is easier to treat and cure. Screenings are performed to diagnose or 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. Each colorectal cancer screening can be used alone or in combination with each other.
Coverage Information
Medicare provides coverage of colorectal cancer screening for the early detection of colorectal cancer. All Medicare beneficiaries age 50 and older are covered; however, when an individual is at high risk, there is no minimum age required to receive a screening colonoscopy or a barium enema rendered as an alternative to a screening colonoscopy.
Medicare provides coverage for colorectal cancer screening as a Medicare Part B benefit. The beneficiary will pay nothing for the FOBT (there is no deductible and no coinsurance or copayment for this benefit). For all other procedures, the coinsurance or copayment applies; however, there is no deductible.
NOTE: Medicare does not waive the deductible if the colorectal cancer screening test becomes a diagnostic colorectal test; that is, the service actually results in a biopsy or removal of a lesion or growth.
If the flexible sigmoidoscopy or colonoscopy procedure is performed in a hospital outpatient department or in an ambulatory surgical center, the beneficiary will pay 25 percent of the Medicare-approved amount.
Coding and Diagnosis Information
G0104 Colorectal cancer screening; flexible sigmoidoscopy
G0105 Colorectal cancer screening; colonoscopy on individual at high risk
G0106 Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema
G0107* Colorectal cancer screening; fecal-occult blood test, 1-3
simultaneous determinations
82270 Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided 3 cards or single triple card for consecutive collection)
G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema
G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0122 Colorectal cancer screening; barium enema
G0328 Colorectal cancer screening; fecal occult blood test, immunoassay,
Diagnosis Requirements
V10.05 Personal history of malignant neoplasm of large intestine
V10.06 Personal history of malignant neoplasm of rectum, rectosigmoid junction, and anus
555.0 Regional enteritis of small intestine
555.1 Regional enteritis of large intestine
555.2 Regional enteritis of small intestine with large intestine
555.9 Regional enteritis of unspecified site
556.0 Ulcerative (chronic) enterocolitis
556.1 Ulcerative (chronic) ileocolitis
556.2 Ulcerative (chronic) proctitis
556.3 Ulcerative (chronic) proctosigmoiditis
556.8 Other ulcerative colitis
556.9Ulcerative colitis, unspecified
Reasons for Claim Denial
The following are examples of situations where Medicare may deny coverage of colorectal cancer screening: `
* The beneficiary is under age 50.
* The beneficiary does not meet the criteria of being at high risk of developing colorectal cancer.
* The beneficiary has exceeded Medicare’s frequency parameters for coverage of colorectal cancer screening services.
CPT code G0105, G0121, g0328 - Colorectal cancer screening
CPT Code and Description
G0105 - Colorectal cancer screening; colonoscopy on individual at high risk
G0104 - Colorectal cancer screening; flexible sigmoidoscopy
G0105 - Colorectal cancer screening; colonoscopy on individual at high risk
G0106 - Colorectal cancer screening; alternative to g0104, screening sigmoidoscopy, barium enema
G0120 - Colorectal cancer screening; alternative to g0105, screening colonoscopy, barium enema.
G0121 - Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0122 - Colorectal cancer screening; barium enema
G0328 - Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous
Colonoscopy Coding - What Happens when a screening becomes diagnostic
Rely on G-Code for Medicare Screenings
Medicare requires that you report colonoscopy screening for eligible patients using either G0105 (Colorectal cancer screening;colonoscopy on individual at high risk) or G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk). These codes define a patient as either “high risk” for colorectal cancer, or “not meeting criteria for high risk.”
Medicare will allow only select diagnoses to support a high risk classification. These may include:
• V10.05 — Personal history of malignant neoplasm; gastrointestinal tract; large intestine
• V10.06 — Personal history of malignant neoplasm, rectum, rectosigmoid junction, and anus
• V12.72 — Personal history of certain other diseases; diseases of digestive system; colonic polyps
• V16.0 — Family history of malignant neoplasm; gastrointestinal tract
• V18.5 — Family history of certain other specific conditions; digestive disorders
Other Medicare- approved diagnoses for G0105 include inflammatory bowel disease, Crohn’s disease and ulcerative colitis.
If the patient meets any of the above criteria, you should list the appropriate risk factor as the primary diagnosis, along with procedure code G0105.
If the patient does not meet any of the high risk criteria for colorectal cancer, you would report procedure code G0121 with a primary diagnosis of V76.51 (Special screening for malignant neoplasms;colon).
For example, to report a covered colonoscopy screening for a 62-year-old male with a personal history of malignant neoplasm of the large intestine, you would link the “high risk” procedure code G0105 to a diagnosis of V10.05.
For an asymptomatic, 50-year-old patient receiving his first Medicare-covered colonoscopy screening, you would instead link a diagnosis of V76.51 to procedure code G0121
HCPCS code G0105
CPT G0105 - Description : Colorectal cancer screening; colonoscopy on individual at high risk
Screening Colonoscopies For Beneficiaries At High Risk Of Developing Colorectal Cancer (Code G0105) .--Pay for screening colonoscopies (code G0105) when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered G0105 screening colonoscopy was performed). The criteria to use in determining whether or not an individual is at high risk for developing colorectal cancer.
NOTE: If during the course of the screening colonoscopy, 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 and paid rather than code G0105.
There are a variety of methods available for colorectal cancer screening, including fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and screening barium enema. It is important that practitioners follow the practice guidelines for screening and follow-up.
Medicare Guidelines
Cancer screening is a means of detecting disease early, in asymptomatic individuals, with the goal of decreasing morbidity and mortality. Generally, screening examinations, tests, or procedures are not diagnostic of cancer but instead indicate that a cancer may be present. The diagnosis is then made following a workup that generally includes a biopsy and pathologic confirmation. Colorectal cancer screening involves the use of fecal occult blood testing, rigid and flexible sigmoidoscopy, radiographic barium contrast studies, and colonoscopy.
Effective for services furnished on or after January 1, 1998, Medicare will cover colorectal cancer screening test/procedures for the early detection of colorectal cancer. The following are the coverage criteria for these screening services:
• Annual fecal occult blood tests (FOBTs);
• Flexible sigmoidoscopy over 4 years;
• Screening colonoscopy for persons at average risk for colorectal cancer every 10 years,
• Screening colonoscopy for persons at high risk* for colorectal cancer every 2 years;
• Barium enema every 4 years as an alternative to flexible sigmoidoscopy, or
• Barium enema every 2 years as an alternative to colonoscopy for persons at high risk* for colorectal cancer;
• Effective for claims with dates of service on or after October 9, 2014, payment may be made for colorectal cancer screening using the Cologuard™ multitarget stool DNA (sDNA) test
* Medicare defines high risk of developing colorectal cancer as someone who has one or more of the following risk factors:
• 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
• A personal history of inflammatory bowel disease, including Crohn’s Disease, and ulcerative colitis
It is not expected that these screening services are performed on patients that present with active gastrointestinal symptomatology.
Billing for Screening Colonoscopy or Sigmoidoscopy
The AMA created modifier 33 to allow providers to identify a preventive service for which, under The PPACA, there is no patient cost sharing. Use modifier 33 with a CPT code for a diagnostic/treatment service performed as a preventive service, such as a screening colonoscopy, even if a polyp is found and removed.
You may also use G codes intended for use for screening procedures for colorectal cancer screening:
o G0105: colonoscopy screening for individuals at high risk
o G0121: colonoscopy screening for individuals who are not high risk
o G0104: flexible sigmoidoscopy screening
When billing for preventive screening colonoscopy or sigmoidoscopy for any BCBSMA member, use modifier 33 or one of the G codes above so that the claim pays without any member cost share, according to the member’s benefits.
Do not use modifier 33 to bill for individuals receiving procedures due to signs or symptoms, or to rule out or confirm a suspected diagnosis. In this case, the procedure would be considered a diagnostic exam, not a screening exam. See the table on page 1 for coding examples. As always, be sure to check eligibility and benefits to determine appropriate member cost-sharing
National Guidelines
National guidelines recommend colorectal cancer screening starting at age 50 then every 10 years. However, more frequent or earlier screening is recommended for patients with certain increased risk factors, such as a family history of colon cancer or personal history of polyps. Screening in these situations will now also be covered when billed as a preventive service.
Screening colonoscopies (code G0105) may be paid when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered G0105 screening colonoscopy was performed). Refer to §60.2 of this chapter for the criteria to use in determining whether or not an individual is at high risk for developing colorectal cancer.
NOTE: If during the course of the screening colonoscopy, 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 and paid rather than code G0105.
G0120 - Colorectal Cancer Screening; Barium Enema; as an Alternative to or
G0105, Screening Colonoscopy
Screening barium enema examinations may be paid as an alternative to a screening colonoscopy (code G0105) examination. The same frequency parameters for screening colonoscopies (see those codes above) apply.
In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination (code G0120) performed after at least 23 months have passed following the month in which the last screening barium enema or the last screening colonoscopy was performed. For example, a beneficiary at high risk for developing colorectal cancer received a screening barium enema examination (code G0120) as an alternative to a screening colonoscopy (code G0105) in January 2000. Start counts beginning February 2000. The beneficiary is eligible for another screening barium enema examination (code G0120) in January 2002.
Denial reason
If the claim is being denied because payment has already been made for a screening fecal-occult blood test (G0107 or G0328), flexible sigmoidoscopy (code G0104), screening colonoscopy (code G0105), or a screening barium enema (codes G0106 or G0120), MSN message 18.16 is used:
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 code G0120 and an incoming claim is submitted for code G0105 within 24 months, the incoming claim should be denied.
Deductible and Coinsurance
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).
When a screening colonoscopy becomes a diagnostic colonoscopy anesthesia code 00810 should be submitted with only the -PT modifier and only the deductible will be 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 January 1, 2015, coinsurance and deductible are waived for anesthesia services CPT 00810, Anesthesia for lower intestinal endoscopic procedures, endoscope introduceddistal to duodenum, when performed for screening colonoscopy services and when billed with Modifier 33.
COLORECTAL CANCER SCREENING
Covered Services and HCPCS Codes.-- Medicare covers colorectal cancer screening test/procedures for the early detection of colorectal cancer for the HCPCS codes indicated.
A. Effective for Services Furnished on or After January 1, 1998.-- G0107--Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations;
G0104--Colorectal cancer screening; flexible sigmoidoscopy;
G0105--Colorectal cancer screening; colonoscopy on individual at high risk;
G0106--Colorectal cancer screening; barium enema; as an alternative to G0104, screening sigmoidoscopy;
G0120--Colorectal cancer screening; barium enema; as an alternative to G0105, screening colonoscopy.
Coverage Criteria.--The following are the coverage criteria for these screenings:
A. Screening Fecal-Occult Blood Tests (Code G0107).--Effective for services furnished on or after January 1, 1998, pay for screening fecal-occult blood tests (code G0107) for beneficiaries who have attained age 50, and at a frequency of once every 12 months (i.e., at least 11 months have passed following the month in which the last covered screening fecal-occult blood test was done). Screening fecal-occult blood test means a guaiac-based test for peroxidase activity, in which the beneficiary completes it by taking samples from two different sites of three consecutive stools.
This screening requires a written order from the beneficiary’s attending physician. (The term “attending physician” is defined to mean a doctor of medicine or osteopathy (as defined in §1861(r) (1) of the Social Security Act) who is fully knowledgeable about the beneficiary’s medical condition, and who would be responsible for using the results of any examination performed in the overall management of the beneficiary’s specific medical problem.)
B. Screening Flexible Sigmoidoscopies (code G0104).—For claims with dates of service on or after January 1, 2002, pay for screening flexible sigmoidoscopies (Code G0104) for beneficiaries who have attained age 50 when these services were performed by a doctor of medicine or osteopathy, or by a physician assistant, nurse practitioner, or clinical nurse specialist at the frequencies noted below. For claims with dates of service prior to January 1, 2002, pay for these services under the conditions noted only when they are performed by a doctor of medicine or osteopathy.
For services furnished from January 1, 1998, through June 30, 2001, inclusive:
Once every 48 months (i.e., at least 47 months have passed following the month in which the last covered screening flexible sigmoidoscopy was done). For services furnished on or after July 1, 2001:
Once every 48 months as calculated above unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer (refer to §4180.3) and he/she has had a screening colonoscopy (code G0121) within the preceding 10 years. If such a beneficiary has had a screening colonoscopy within the preceding 10 years, then he or she can have covered a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that he/she received the screening colonoscopy (code G0121).
NOTE: If during the course of a screening flexible sigmoidoscopy a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a flexible sigmoidoscopy with biopsy or removal should be billed and paid rather than code G0104.
C. Screening Colonoscopies For Beneficiaries At High Risk Of Developing Colorectal Cancer (Code G0105).--Pay for screening colonoscopies (code G0105) when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered G0105 screening colonoscopy was performed). Refer to §4180.3 for the criteria to use in determining whether or not an individual is at high risk for developing colorectal cancer.
NOTE: If during the course of the screening colonoscopy, 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 and paid rather than code G0105.
D. Screening Colonoscopies Performed on Individuals Not Meeting the Criteria for Being at High-Risk for Developing Colorectal Cancer (Code G0121).--Effective for services furnished on or after July 1, 2001, pay for screening colonoscopies (code G0121) performed under the following conditions:
1. On individuals not meeting the criteria for being at high risk for developing colorectal cancer (refer to §4180.3).
2. At a frequency of once every 10 years (i.e., at least 119 months have passed following the month in which the last covered G0121 screening colonoscopy was performed).
3. If the individual would otherwise qualify to have covered a G0121 screening colonoscopy based on the above (see §4180.2.D.1 and .2) but has had a covered screening flexible sigmoidoscopy (code G0104), then he or she may have covered a G0121 screening colonoscopy only after at least 47 months have passed following the month in which the last covered G0104 flexible sigmoidoscopy was performed.
NOTE: If during the course of the screening colonoscopy, 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 and paid rather than code G012
E. Screening Barium Enema Examinations (codes G0106 and G0120).--Screening barium enema examinations are covered as an alternative to either a screening sigmoidoscopy (code G0104) or a screening colonoscopy (code G0105) examination. The same frequency parameters for screening sigmoidoscopies and screening colonoscopies (see §4180.2 B and C) above apply.
In the case of an individual aged 50 or over, payment may be made for a screening barium enema examination (code G0106) performed after at least 47 months have passed following the month in which the last screening barium enema or screening flexible sigmoidoscopy was performed. For example, the beneficiary received a screening barium enema examination as an alternative to a screening flexible sigmoidoscopy in January 1998. Start your count beginning February 1998. The beneficiary is eligible for another screening barium enema in January 2002.
In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination (code G0120) performed after at least 23 months have passed following the month in which the last screening barium enema or the last screening colonoscopy was performed. For example, a beneficiary at high risk for developing colorectal cancer received a screening barium enema examination (code G0120) as an alternative to a screening colonoscopy (code G0105) in January 1998. Start your count beginning February 1998. The beneficiary is eligible for another screening barium enema examination (code G0120) in January 2000.
The screening barium enema must be ordered in writing after a determination that the test is the appropriate screening test. Generally, it is expected that this will be a screening double contrast enema unless the individual is unable to withstand such an exam. This means that in the case of a particular individual, the attending physician must determine that the estimated screening potential for the barium enema is equal to or greater than the screening potential that has been estimated for a screening flexible sigmoidoscopy, or for a screening colonoscopy, as appropriate, for the same individual. The screening single contrast barium enema also requires a written order from the beneficiary’s attending physician in the same manner as described above for the screening double contrast barium enema examination
Noncovered Services.--The following noncovered 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 screening; 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 noncovered 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 screening; 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 noncovered because it fails to meet the requirements of the benefit. The beneficiary is liable for payment.
Payment Requirements.--Code G0107 (colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations) must be paid at the rates established for this code under the clinical laboratory fee schedule.
Code G0104 (colorectal cancer screening; flexible sigmoidoscopy) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic flexible sigmoidoscopy (CPT code 45330). (The same RVUs have been assigned to code G0104 as those assigned to CPT code 45330.) If during the course of a screening flexible sigmoidoscopy a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate procedure classified as a flexible sigmoidoscopy with biopsy or removal must be billed and paid rather than code G0104.
Codes G0105 and G0121 (colorectal cancer screening colonoscopies) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic colonoscopy (CPT code 45378). (The same RVUs have been assigned to codes G0105 and G0121 as those assigned to CPT code 45378.) If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate procedure classified as a colonoscopy with biopsy or removal must be billed and paid rather than code G0105 or G0121.
Code G0106 (colorectal cancer screening; barium enema as an alternative to a screening flexible sigmoidoscopy) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic barium enema (CPT code 74280).
Code G0120 (colorectal cancer screening; barium enema as an alternative to a screening colonoscopy; high risk individuals) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic barium enema (CPT code 74280).
No comments:
Post a Comment