Coverage For Medicare Colonoscopies

Erika Stevens, CPC - Senior Professional Physician Coding Specialist Inpatient Coding Leave a Comment

Coverage For Medicare Colonoscopies

Colonoscopies are critical to our well being. How these important services are documented and coded is equally as important. Medicare covers screening colonoscopies every 24 months if the patient is at high risk for colon cancer or once every 120 months, or 48 months after a previous flexible sigmoidoscopy.

No cost to the beneficiary for screening colonoscopies and the provider accepts assignment.

However, if the provider starts a screening colonoscopy and removes a polyp or another issue is found and removed during the screening colonoscopy, it turns into a diagnostic service and 20% of the Medicare allowable is the patient’s responsibility.  The Part B deductible does not apply.  This applies to all screening colonoscopies.

Colorectal Cancer Screening Services

HCPCS G0104 – Colorectal Cancer Screening; Flexible Sigmoidoscopy

  • Covered once every 48 months unless the patient does not meet the criteria for high risk of developing colorectal cancer and the patient has had a screening colonoscopy (G0121) within the preceding 10 years. If such a patient has had a screening colonoscopy within the preceding 10 years, then the patient can have covered screening flexible sigmoidoscopy only after at least 119 months have passed following the month that the patient received the screening colonoscopy (G0121).
    • NOTE: If during the screening flexible sigmoidoscopy a lesion growth is detected which results in a biopsy or removal, the appropriate diagnostic procedure (CPT code) classified as a flexible sigmoidoscopy with biopsy or removal along with modifier -PT should be billed and paid rather than HCPCS G0104.

HCPCS G0105 – Colorectal Cancer Screening; Colonoscopy on Individuals at High Risk

  • An individual at high risk for developing colorectal cancer has one or more of the following:
    • 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
    • Inflammatory bowel disease, including Crohn’s Disease, and ulcerative colitis
  • NOTE: When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances, Medicare will pay for the interrupted colonoscopy as long as the coverage conditions are met for the incomplete procedure.

HCPCS G0106 – Colorectal Cancer Screening; Barium Enema; as an Alternative to HCPCS G0104, Screening Sigmoidoscopy

  • Screening barium enema examinations may be paid as an alternative to a screening sigmoidoscopy (G0104). The same frequency parameters for screening sigmoidoscopies apply.
  • 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 for the same individual.  The screening single contrast barium enema also requires a written order from the patient’s attending physician in the same manner as described above for the screening double contrast barium enema examination.

HCPCS G0121 – Colorectal Screening; Colonoscopy on Individual Not Meeting Criteria for High Risk

  • At a frequency of once every 10 years (at least 119 months have passed following the month in which the last covered G0121 screening colonoscopy was performed)
  • If the individual would otherwise qualify to have covered a G0121 screening colonoscopy based on the above but has had a covered screening flexible sigmoidoscopy, then the individual may have a covered G0121 screening colonoscopy only after at least 47 months have passed following the month in which the last covered G0104 flexible sigmoidoscopy was performed.

 

COLORECTAL CANCER SCREENING GUIDELINES

Colorectal Cancer Screening Test/Procedure

CPT/HCPCS Code

Medicare Coverage

Screening Fecal-Occult Blood Test

82270 G0328

Once every 12 months for patients aged 50 and older

Screening Flexible Sigmoidoscopy

G0104

Once every 48 months for patients aged 50 and older when performed by an MD, DO, PA, NP, or CNS

Screening Colonoscopy – individual at high risk

G0105

Once every 24 months for patients of any age who are at high risk for colorectal cancer, when performed by an MD or DO

Screening Colonoscopy – individual not meeting criteria for high risk

G0121

Once every 10 years but not within 48 months of a screening sigmoidoscopy for patient at any age who are not at high risk, when performed by a MD or DO

Screening Barium Enema – alternative to G0104

G0106

Physicians may substitute a barium enema examination for flexible sigmoidoscopy every 4 years for patients aged 50 or older

Screening Barium Enema – alternative to G0105

G0120

Physicians may substitute a barium enema examination for colonoscopy every 2 years for high-risk patients

Screening Barium Enema – not performed as an alternative to G0105 or G0104

G0122

This service is denied as noncovered because it fails to meet the requirements of the benefit.  The patient is liable for payment

Relevant Resources

Billing and Coding: Colorectal Cancer Screening

Medicare.gov Colonoscopies 

 

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