Medicare covers colorectal cancer screening tests to help find pre-cancerous polyps (growths in the colon), so polyps can be removed before they become cancerous and to help find colorectal cancer at an early stage when treatment works best.

Expanded Coverage! Medicare began covering the Cologuard™ Multitarget Stool DNA (sDNA) Test effective October 9, 2014.

Effective January 1, 2016, use CPT code 81528 when billing for the Cologuard™ test (note that your MAC will accept HCPCS code G0464 for claims with dates of service on or before December 31, 2015).

Only laboratories authorized by the manufacturer to perform the Cologuard test may bill for this test.

Who Is Covered

For colorectal cancer screening using Cologuard™—a Multitarget Stool DNA (sDNA) Test:

   • All Medicare beneficiaries:

      • Aged 50 to 85 years;

      • Asymptomatic; and

      • At average risk of developing colorectal cancer, meaning they have no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis.

For screening colonoscopies, FOBTs, flexible sigmoidoscopies, and barium enemas:

   • All Medicare beneficiaries:

      • Aged 50 and older who are at normal risk of developing colorectal cancer; or

      • At high risk of developing colorectal cancer

Note: "High risk for developing colorectal cancer" is defined in the Code of Federal Regulations (CFR) at 42 CFR 410.37(a)(3).
Note: For coverage of screening colonoscopies, there is no age limitation.

HCPCS/CPT Codes

00810 - Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum

81528 - Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result

82270 - Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection)

G0104 - Flexible Sigmoidoscopy

G0105 - Colonoscopy (high risk)

G0106 - Barium Enema (alternative to G0104)

G0120 - Barium Enema (alternative to G0105)

G0121 - Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3)

G0328 - Fecal Occult Blood Test (FOBT), immunoassay, 1-3 simultaneous

ICD-10-CM Codes

See the CMS ICD-10 webpage for individual Change Requests (CRs) and coding translations for ICD-10 and contact your Medicare Administrative Contractor (MAC) for guidance.

Z12.11 - Cologuard Multitarget Stool DNA (sDNA) Test

Z12.12 - Cologuard Multitarget Stool DNA (sDNA) Test

Frequency

Normal Risk:

   • Cologuard Multitarget Stool DNA (sDNA) Test: once every 3 years

   • Screening FOBT: every year

   • Screening flexible sigmoidoscopy: once every 4 years (unless a screening colonoscopy has been performed and then Medicare may cover a screening flexible sigmoidoscopy only after at least 119 months)

   • Screening colonoscopy: every 10 years (unless a screening flexible sigmoidoscopy has been performed and then Medicare may cover a screening colonoscopy only after 47 months)

   • Screening barium enema (as an alternative to covered screening flexible sigmoidoscopy)

High Risk:

   • Screening FOBT: every years

   • Screening flexible sigmoidoscopy: once every 4 years

   • Screening colonoscopy: every 2 years (unless a screening flexible sigmoidoscopy has been performed and then Medicare may cover a screening colonoscopy only after at least 47 months)

   • Screening barium enema (as an alternative to covered screening flexible sigmoidoscopy or colonoscopy)

Medicare Beneficiary Pays

81528, 82270, G0104, G0105, G0121, G0328, and G0464:

   • Copayment waived

   • Coinsurance waived

   • Deductible waived

   Note: Append modifier -33 to the anesthesia CPT code 00810 when you furnish a separately payable anesthesia service in conjunction with a screening colonoscopy (G0105 and G0121) to waive Medicare beneficiary copayment/coinsurance and deductible.

G0106 and G0120:

   • Copayment applies

   • Coinsurance applies

   • Deductible waived

   Note: No deductible for all surgical procedures (CPT code range of 10000 to 69999) furnished on the same date and in the same encounter as a screening colonoscopy, flexible sigmoidoscopy, or barium enema initiated as colorectal cancer screening services.

   Note: Append modifier -PT to CPT code in the surgical range of 10000 to 69999 in this scenario.

   Note: For Colorectal Cancer Screening, effective January 1, 2015, when anesthesia service 00810 is performed in conjunction with screening colonoscopy services G0105 or G0121, coinsurance and deductible will be waived for anesthesia service 00810 when modifier 33 is entered on the anesthesia claim.

   Note: 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.

References