Procedure code and Description
• CPT 82270 (HCPCS G0107) – Colorectal cancer screening; fecal-occult blood tests, 1-3 simultaneousdeterminations;
• HCPCS G0104 – Colorectal cancer screening; flexible sigmoidoscopy;
• HCPCS G0105 – Colorectal cancer screening; colonoscopy on individual at high risk;
• HCPCS G0106 – Colorectal cancer screening; barium enema; as an alternative to HCPCS G0104, screening sigmoidoscopy;
• HCPCS G0120 – Colorectal cancer screening; barium enema; as an alternative to HCPCS G0105, screening colonoscopy.
Medicare Billing Guidelines
G0104 – Colorectal Cancer Screening; Flexible Sigmoidoscopy Screening flexible sigmoidoscopies (HCPCS G0104) may be paid for beneficiaries who have attained age 50, when performed by a doctor of medicine or osteopathy at the frequencies noted below.
HCPCS G0120 – Colorectal Cancer Screening; Barium Enema; as an Alternative to HCPCS G0105, Screening Colonoscopy Screening barium enema examinations may be paid as an alternative to a screening colonoscopy (HCPCS 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 (HCPCS 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 (HCPCS G0120) as an alternative to a screening colonoscopy (HCPCS G0105) in January 2000.
Start counts beginning February 2000. The beneficiary is eligible for another screening barium enema examination (HCPCS G0120) in January 2002.
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 colonoscopy, 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 bariumenema examination.
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.
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).
COLORECTAL CANCER SCREENING TESTS OVERVIEW
The following services are considered colorectal cancer screening services:
• Annual fecal occult blood tests (FOBTs);
• Flexible sigmoidoscopy;
• 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*;
• CologuardTM – Multitarget Stool DNA (sDNA) Test (effective October 9, 2014)
*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, C rohn’s Disease, and ulcerative colitis
It is not expected that these screening services are performed on patients that present with active gastrointestinal symptomatology.
Remittance Advice Notices.Denial codes
A. If the claim for a screening fecal-occult blood test, a screening flexible sigmoidoscopy, or a screening barium enema is being denied because the patient is under 50 years of age, use existing American National Standard Institute (ANSI) X12-835 claim adjustment reason code 6 “the procedure code is inconsistent with the patient’s age,” at the line level along with line level remark code M82 “Service is not covered when beneficiary is under age 50.”
B. If the claim for a screening fecal-occult blood test, a screening colonoscopy, a screening flexible sigmoidoscopy, or a screening barium enema is being denied because the time period between the test/procedure has not passed, use existing ANSI X12-835 claim adjustment reason code 119 “Benefit maximum for this time period has been reached” at the line level.
C. If the claim is being denied for a screening colonoscopy (code G0105) or a screening barium enema (G0120) because the beneficiary is not at a high risk, use existing ANSI X12-835 claim adjustment reason code 46 “This procedure is not covered” at the line level along with line level remark code M83 “Service is not covered unless the beneficiary is classified as a high risk.”
D. If the service is being denied because payment has already been made for a similar procedure within the set time frame, use existing ANSI X12-835 claim adjustment reason code 18, “Duplicate claim/service” at the line level along with line level remark code M86 “This service is denied because payment has already been made for a similar procedure within a set timeframe.”
E. If the claim is being denied for a noncovered screening procedure such as G0122, use existing ANSI X12-835 claim adjustment reason code 49, “These are non-covered services because this is a routine exam or screening procedure done in conjunction with a routine exam.” 4180.10 Ambulatory Surgical Center Facility Fee.–CPT code 45378, which is used to code a diagnostic colonoscopy, is on the list of procedures approved by Medicare for payment of an ambulatory surgical center (ASC) facility fee under §1833(I) of the Act. CPT code 45378 is currently assigned to ASC payment group 2. Code G0105 (colorectal cancer screening; colonoscopy on individual at high risk) has been added to the ASC list effective for services furnished on or after January 1, 1998. Code G0121 (colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) was added to the ASC list effective for services furnished on or after July 1, 2001. Codes G0105 and G0121 are assigned to ASC payment group 2. The ASC facility service is the same whether the procedure is a screening or a diagnostic colonoscopy.3
Covered ICD codes
Routine screening examinations:
V76.41 SCREENING FOR MALIGNANT NEOPLASMS OF THE RECTUM
V76.51 SPECIAL SCREENING FOR MALIGNANT NEOPLASMS COLON
Screening examinations for persons at high risk: (HCPCS Codes G0105 and G0120)
Personal or family history of gastrointestinal neoplasia:
211.3 BENIGN NEOPLASM OF COLON
211.4 BENIGN NEOPLASM OF RECTUM AND ANAL CANAL
235.2 NEOPLASM OF UNCERTAIN BEHAVIOR OF STOMACH INTESTINES AND
RECTUM
V10.00 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF UNSPECIFIED SITE IN
GASTROINTESTINAL TRACT
V10.05* PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LARGE INTESTINE
V10.06* PERSONAL HISTORY OF MALIGNANT NEOPLASM OF RECTUM
RECTOSIGMOID JUNCTION AND ANUS
V10.07 PERSONAL HISTORY OF MALIGNANT NEOPLASM OF LIVER
V12.72 PERSONAL HISTORY OF COLONIC POLYPS
V12.79 PERSONAL HISTORY OF OTHER SPECIFIED DIGESTIVE SYSTEM DISEASES
V16.0 FAMILY HISTORY OF MALIGNANT NEOPLASM OF GASTROINTESTINAL
TRACT
V18.51 FAMILY HISTORY, COLONIC POLYPS
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
556.4 PSEUDOPOLYPOSIS OF COLON
556.5 LEFT-SIDED ULCERATIVE (CHRONIC) COLITIS
556.6 UNIVERSAL ULCERATIVE (CHRONIC) COLITIS
556.8* OTHER ULCERATIVE COLITIS
556.9* ULCERATIVE COLITIS UNSPECIFIED