Medicare Colorectal Cancer Screening Services
Medicare Covers a Variety of Tests for
By Jackie Miller, RHIA, CCS-P, CPC
According 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 CLIA-waived 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 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 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
- A personal history of inflammatory bowel disease, including Crohn's disease and ulcerative colitis
Screening colonoscopy is the most effective way to detect colorectal cancer and precancerous polyps. However, it is also relatively costly and requires a strenuous prep, moderate sedation, and – if the patient is employed – time away from work. Screening colonoscopy is reported with the following HCPCS codes, depending on whether the patient has any of the high-risk criteria listed previously:
- G0105: Colorectal cancer screening; colonoscopy on individual at high risk
- G0121: Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
A screening colonoscopy must be performed by a physician. There is no minimum age for coverage. If the physician performs a biopsy or lesion removal during a screening colonoscopy, the procedure should be reported as a diagnostic colonoscopy using the appropriate CPT code.
For patients at high risk of colorectal cancer, Medicare will cover screening colonoscopy (G0105) once every two years. At least 23 months must have passed since the month in which the previous screening colonoscopy was performed. For patients at normal risk of colorectal cancer, Medicare will cover screening colonoscopy (G0121) once every 10 years (at least 119 completed months since the last colonoscopy). If a normal-risk patient's prior screening was a sigmoidoscopy rather than a colonoscopy, then only four years (47 completed months) must elapse before the patient is eligible for coverage of a screening colonoscopy.
A barium enema is a fluoroscopic exam of the colon performed by instilling barium sulfate into the rectum. For a double-contrast barium enema, also called an air-contrast barium enema, air is also pumped into the colon to distend it and make abnormalities easier to see. A barium enema is not an optimal test for cancer screening since small lesions can be easily missed. However, Medicare will cover screening barium enemas under limited circumstances. The exam is reported with the following HCPCS codes:
- G0106: Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema
- G0120: Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema
The screening barium enema must be ordered in writing by a physician after determining that the procedure is appropriate. Specifically, the physician must establish that the estimated screening potential for a barium enema exam of the patient in question is equal to or greater than the screening potential for a screening sigmoidoscopy or colonoscopy of the same patient. The Medicare Benefit Policy Manual (chapter 15, section 280.2.2.E) states, "Generally, it is expected that this will be a screening double contrast enema unless the individual is unable to withstand such an exam." If the patient is unable to undergo a double-contrast barium enema, then a single-contrast barium enema can be performed.
For patients at high risk for colorectal cancer, a screening barium enema performed as an alternative to colonoscopy (G0105) is reported with code G0120. Medicare will pay for this procedure every two years (at least 23 completed months since the last screening barium enema or colonoscopy). There is no age limit.
For patients at normal risk for colorectal cancer, a screening barium enema performed as an alternative to sigmoidoscopy (G0104) is reported with code G0106. Medicare will pay for this procedure every four years (at least 47 completed months since the last screening barium enema or sigmoidoscopy). The patient must be age 50 or older.
If a patient chooses to have a screening barium enema but does not meet the criteria listed above, Medicare will not pay for the procedure. If the patient wants a claim submitted to Medicare in order to obtain a denial for a secondary insurance, the provider should use code G0122 (colorectal cancer screening; barium enema). This code should not be used for covered barium enema exams.
By ICD-9-CM and ICD-10-CM guidelines, the primary diagnosis code for an exam performed to screen for cancer should be a screening code—for example, code V76.51 (special screening for malignant neoplasms; colon) in ICD-9-CM or code Z12.11 (encounter for screening for malignant neoplasm of colon) in ICD-10-CM.
High-risk patients will require an additional diagnosis code to reflect the specific risk factor. It is important to capture this information so that the Medicare contractor can apply the correct frequency guidelines. The Medicare Benefit Policy Manual (see the link in the Resources section) contains a list of ICD-9-CM codes for high-risk diagnoses but also states that Medicare contractors may identify additional codes that will be covered as high risk.
Findings of the exam should be reported as a secondary diagnosis. For example, if a screening reveals an abnormality like a polyp or diverticulosis, the screening code should be reported first, followed by the code for the finding and the code for the high-risk condition, if applicable.
Individual Medicare contractors and non-Medicare payors may have specific preferences for diagnosis code assignment, so it is important to review any relevant published payor guidelines before submitting claims.
For Medicare coverage guidelines for colorectal cancer screening, see the Medicare Benefit Policy Manual, chapter 15, section 280.2: http://www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/Downloads/bp102c15.pdf
For information on billing and reimbursement for colorectal cancer screening, see the Medicare Claims Processing Manual, chapter 18, section 60: http://www.cms.gov/
"MLN Matters" article SE0746 discusses code assignment for a screening colonoscopy that results in a polypectomy: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0746.pdf
For other information about Medicare preventive services, see: