Medicare Colorectal Cancer Screening Services MEDICARE COVERS A VARIETY OF TESTS FOR EARLY DETECTION By Jackie Miller, RHIA, CCS-P, CPC ccording to the Centers for Disease Control and Prevention, more than 50,000 people died of colorectal cancer in the US during 2010, the most recent year for which statistics are available. Medicare covers a number of different tests for early detection of this devastating disease, and in this month’s column, we will review the screening options and the coverage restrictions. Fecal Occult Blood Test The fecal occult blood test (FOBT) is a relatively low-cost method of screening for colorectal cancer. It relies on the fact that colon cancers usually shed blood cells into the stool. There are two commonly used methods for testing the stool. For the first method, a stool guaiac test, the patient smears a tiny amount of stool onto a special test card each day for three days. Laboratory personnel then apply hydrogen peroxide to the card, and if blood is present, the paper changes color. The stool guaiac test has been available for many years, and the cost is nominal compared to other types of screening. Another stool test is the fecal immunochemical test (FIT), which uses antibodies to detect the presence of globin in the stool. FIT is much more accurate than the stool guaiac test, but it is also more expensive (though, it is still much less costly than a colonoscopy). Medicare covers both types of FOBTs for early detection of colorectal cancer. (A third type of fecal test, which extracts DNA from the stool, is not covered for screening purposes.) A screening FOBT is reported with the following codes: • 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 three cards or single triple card for consecutive collection) • G0328: Colorectal cancer screening; fecal occult blood test, immunoassay, one to three simultaneous Only one unit of the code should be reported for simultaneous testing of one to three specimens. When performed as a CLIAwaived 28 HBMA BILLING • JULY.AUGUST.2014 test, code G0328 must be submitted with modifier “QW.” Medicare covers one screening FOBT per year for beneficiaries ages 50 or older. The test must be ordered by the patient’s treating physician. Either a stool guaiac test or a FIT will be covered, but not both. Also, at least 11 months must have passed since the month of the patient’s last test. Flexible Sigmoidoscopy Flexible sigmoidoscopy is the use of a flexible endoscope to view the distal portion of the colon up to the splenic flexure (about 60 centimeters from the anus). This procedure cannot detect cancers or polyps in the proximal part of the colon. However, unlike a colonoscopy, it does not require sedation, and the prep is less rigorous. A screening flexible sigmoidoscopy is reported with the following HCPCS code: • G0104: Colorectal cancer screening; flexible sigmoidoscopy The procedure can be performed by a physician or nonphysician practitioner (physician assistant, nurse practitioner, or clinical nurse specialist). If a lesion or growth is biopsied or removed during a screening sigmoidoscopy, the procedure is reported as a diagnostic sigmoidoscopy using the appropriate Current Procedural Terminology (CPT) code rather than code G0104. Modifier PT (colorectal cancer screening test; converted to diagnostic test or other procedure) should be applied to the diagnostic sigmoidoscopy code to show that the procedure began as a screening. Medicare will cover a screening flexible sigmoidoscopy once every four years. At least 47 months must have passed since the month in which the prior sigmoidoscopy was performed. If the patient’s last screening was a colonoscopy rather than a sigmoidoscopy, then he or she must wait 10 years (119 completed months) after the colonoscopy before being eligible for a screening sigmoidoscopy to be covered. However, this requirement does not apply if the patient is at high risk for colorectal cancer. The Centers for Medicare & Medicaid Services (CMS) defines a high-risk patient as one who has one or more of the following factors: A
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