Monday, July 12, 2010

CPT code G0105, G0121, g0328 - Colorectal cancer screening

CPT Code and Description


G0105 - Colorectal cancer screening; colonoscopy on individual at high risk

G0104 - Colorectal cancer screening; flexible sigmoidoscopy

G0105 - Colorectal cancer screening; colonoscopy on individual at high risk

G0106 - Colorectal cancer screening; alternative to g0104, screening sigmoidoscopy, barium enema

G0120 - Colorectal cancer screening; alternative to g0105, screening colonoscopy, barium enema.

G0121 - Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

G0122 - Colorectal cancer screening; barium enema


G0328 - Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous


Colonoscopy Coding - What Happens when a screening becomes diagnostic

Rely on G-Code for Medicare Screenings

Medicare requires that you report colonoscopy screening for eligible patients using either G0105 (Colorectal cancer screening;colonoscopy on individual at high risk) or G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk). These codes define a patient as either “high risk” for colorectal cancer, or “not meeting criteria for high risk.”

Medicare will allow only select diagnoses to support a high risk classification. These may include:

• V10.05 — Personal history of malignant neoplasm; gastrointestinal tract; large intestine

• V10.06 — Personal history of malignant neoplasm, rectum, rectosigmoid junction, and anus

• V12.72 — Personal history of certain other diseases; diseases of digestive system; colonic polyps

• V16.0 — Family history of malignant neoplasm; gastrointestinal tract

• V18.5 — Family history of certain other specific conditions; digestive disorders

Other Medicare- approved diagnoses for G0105 include inflammatory bowel disease, Crohn’s disease and ulcerative colitis.

If the patient meets any of the above criteria, you should list the appropriate risk factor as the primary diagnosis, along with procedure code G0105.

If the patient does not meet any of the high risk criteria for colorectal cancer, you would report procedure code G0121 with a primary diagnosis of V76.51 (Special screening for malignant neoplasms;colon).

For example, to report a covered colonoscopy screening for a 62-year-old male with a personal history of malignant neoplasm of the large intestine, you would link the “high risk” procedure code G0105 to a diagnosis of V10.05.

For an asymptomatic, 50-year-old patient receiving his first Medicare-covered colonoscopy screening, you would instead link a diagnosis of V76.51 to procedure code G0121



Colorectal Cancer Screening

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 billfor this test.

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 (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., 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 – Colonoscopy (not high risk)

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

G0464 – Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3)



ICD-10 Codes

See the CMS ICD-10 webpage for individual CRs and coding translations for ICD-10 and contact your MAC for guidance

For Cologuard Multitarget Stool DNA (sDNA) Test, use Z12.11 and Z12.12


Who Is Covered

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

All Medicare beneficiaries who fall into all of the following categories:


* Aged 50 to 85 years

* Asymptomatic

* At average risk of developing colorectal cancer

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

All Medicare beneficiaries who fall into at least one of the following categories:

* Aged 50 and older who are at normal risk of developing colorectal cancer 

* At high risk of developing colorectal cancer “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 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 year

* 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) 





HCPCS code G0105

CPT G0105 - Description : Colorectal cancer screening; colonoscopy on individual at high risk


Screening  Colonoscopies For Beneficiaries At High Risk Of Developing Colorectal Cancer (Code  G0105)
.--Pay for screening  colonoscopies  (code  G0105)  when  performed  by  a  doctor  of medicine  or  osteopathy  at  a  frequency  of  once  every  24  months  for  beneficiaries  at  high  risk  for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered G0105 screening colonoscopy was performed).  The criteria to use in determining whether or not an individual is at high risk for developing colorectal cancer.


NOTE:

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  diagnostic  procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than code G0105.

There are a variety of methods available for colorectal cancer screening, including fecal occult blood testing, flexible  sigmoidoscopy, colonoscopy, and screening barium enema. It is important that practitioners follow the practice guidelines for screening and follow-up. 



Medicare Guidelines


Cancer screening is a means of detecting disease early, in asymptomatic individuals, with the goal of decreasing morbidity and mortality. Generally, screening examinations, tests, or procedures are not diagnostic of cancer but instead indicate that a cancer may be present. The diagnosis is then made following a workup that generally includes a biopsy and pathologic confirmation. Colorectal cancer screening involves the use of fecal occult blood testing, rigid and flexible sigmoidoscopy, radiographic barium contrast studies, and colonoscopy. 

Effective for services furnished on or after January 1, 1998, Medicare will cover colorectal cancer screening test/procedures for the early detection of colorectal cancer. The following are the coverage criteria for these screening services:

Annual fecal occult blood tests (FOBTs); 
Flexible sigmoidoscopy over 4 years;
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* for colorectal cancer; 
Effective for claims with dates of service on or after October 9, 2014, payment may be made for colorectal cancer screening using the Cologuard™ multitarget stool DNA (sDNA) test

* 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, including Crohn’s Disease, and ulcerative colitis

It is not expected that these screening services are performed on patients that present with active gastrointestinal symptomatology.

Screening Colonoscopy HCPCS Code G0105

Service is not covered unless the beneficiary is classified as a high risk.

Medicare coverage for a screening colonoscopy is based on patient risk. For beneficiaries 50 and older not considered to be at high risk for developing colorectal cancer, Medicare covers one screening colonoscopy every 10 years, but not within 47 months of a previous screening flexible sigmoidoscopy. Refer to HCPCS code G0121.

Billing for Screening Colonoscopy or Sigmoidoscopy

The AMA created modifier 33 to allow providers to identify a preventive service for which, under  The PPACA, there is no patient cost sharing. Use modifier 33 with a CPT code for a diagnostic/treatment service performed as a preventive service, such as a screening colonoscopy, even if a polyp is found and removed.

You may also use G codes intended for use for screening procedures for colorectal cancer  screening:

o G0105: colonoscopy screening for individuals at high risk
o G0121: colonoscopy screening for individuals who are not high risk
o G0104: flexible sigmoidoscopy screening

When billing for preventive screening colonoscopy or sigmoidoscopy for any BCBSMA member, use modifier 33 or one of the G codes above so that the claim pays without any member cost share, according to the member’s benefits.

Do not use modifier 33 to bill for individuals receiving procedures due to signs or symptoms, or to rule out or confirm a suspected diagnosis. In this case, the procedure would be considered a diagnostic exam, not a screening exam. See the table on page 1 for coding examples. As always, be sure to check eligibility and benefits to determine appropriate member cost-sharing



National Guidelines


National guidelines recommend colorectal cancer screening starting at age 50 then every 10 years. However, more frequent or earlier screening is recommended for patients with certain increased risk factors, such as a family history of colon cancer or personal history of polyps. Screening in these situations will now also be covered when billed as a preventive service.



Screening colonoscopies (code G0105) may be paid when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered G0105 screening colonoscopy was performed). Refer to §60.2 of this chapter for the criteria to use in determining whether or not an individual is at high risk for developing colorectal cancer.

NOTE: 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 diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than code G0105. 

G0120 - Colorectal Cancer Screening; Barium Enema; as an Alternative to or

G0105, Screening Colonoscopy

Screening barium enema examinations may be paid as an alternative to a screening colonoscopy (code 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 (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 2000. Start counts beginning February 2000. The beneficiary is eligible for another screening barium enema examination (code G0120) in January 2002. 

Denial reason

If the claim is being denied because payment has already been made for a screening fecal-occult blood test (G0107 or G0328), flexible sigmoidoscopy (code G0104), screening colonoscopy (code G0105), or a screening barium enema (codes G0106 or G0120), MSN message 18.16 is used:

This service is denied because payment has already been made for a similar procedure within a set timeframe.


NOTE: MSN message 18-16 should only be used when a certain screening procedure is performed as an alternative to another screening procedure. For example: If the claims history indicates a payment has been made for code G0120 and an incoming claim is  submitted for code G0105 within 24 months, the incoming claim should be denied. 

Deductible and Coinsurance

There is no deductible and no coinsurance or copayment for the FOBTs (HCPCS G0107, G0328), flexible sigmoidoscopies (G0104), colonoscopies on individuals at high risk (HCPCS G0105), or colonoscopies on individuals not meeting criteria of high risk (HCPCS G0121). 

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

Prior to January 1, 2007 deductible and coinsurance apply to other colorectal procedures (HCPCS G0106 and G0120). After January 1, 2007, the deductible is waived for those tests. Coinsurance applies.


Effective January 1, 2015, coinsurance and deductible are waived for anesthesia services CPT 00810, Anesthesia for lower intestinal endoscopic procedures, endoscope introduceddistal to duodenum, when performed for screening colonoscopy services and when billed  with Modifier 33.


COLORECTAL CANCER SCREENING

Covered Services and HCPCS Codes.-- Medicare covers colorectal cancer screening test/procedures for the early detection of colorectal cancer for the HCPCS codes indicated.

A. Effective for Services Furnished on or After January 1, 1998.-- G0107--Colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations;

G0104--Colorectal cancer screening; flexible sigmoidoscopy;

G0105--Colorectal cancer screening; colonoscopy on individual at high risk;

G0106--Colorectal cancer screening; barium enema; as an alternative to G0104, screening sigmoidoscopy;

G0120--Colorectal cancer screening; barium enema; as an alternative to G0105, screening colonoscopy.


cpt g0121

Ambulatory Surgical Center Fee, is updated to reflect the addition of Code G0121,(colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) to the ASC list effective for claims with dates of service on or after July 1, 2001.

For services furnished on or after July 1, 2001:

Once every 48 months as calculated above unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer (refer to §4180.3) and he/she has had a screening colonoscopy (code G0121) within the preceding 10 years. If such a beneficiary has had a screening colonoscopy within the preceding 10 years, then he or she can have covered a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that he/she received the screening colonoscopy (code G0121).

Screening Colonoscopies Performed on Individuals Not Meeting the Criteria for Being at High-Risk for Developing Colorectal Cancer (Code G0121).--Effective for services furnished on or after July 1, 2001, pay for screening colonoscopies (code G0121) performed under the following conditions:

1. On individuals not meeting the criteria for being at high risk for developing colorectal cancer (refer to §4180.3).

2. At a frequency of once every 10 years (i.e., at least 119 months have passed following the month in which the last covered G0121 screening colonoscopy was performed).

3. If the individual would otherwise qualify to have covered a G0121 screening colonoscopy based on the above (see §4180.2.D.1 and .2) but has had a covered screening flexible sigmoidoscopy (code G0104), then he or she may have covered a G0121 screening colonoscopy only after at least 47 months have passed following the month in which the last covered G0104 flexible sigmoidoscopy was performed.

NOTE: 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 diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than code G0121.

A. From January 1, 1998 Through June 30, 2001, Inclusive.--Code G0121 (colorectal cancer screening; colonoscopy on an individual not meeting criteria for high risk) should be used when this procedure is performed on a beneficiary who does NOT meet the criteria for high risk. This service should be denied as noncovered because it fails to meet the requirements of the benefit for these dates of service. The beneficiary is liable for payment. Note that this code is a covered service for dates of service on or after July 1, 2001.

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.

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.



Coverage Criteria.--The following are the coverage criteria for these screenings:

A. Screening Fecal-Occult Blood Tests (Code G0107).--Effective for services furnished on or after January 1, 1998, pay for screening fecal-occult blood tests (code G0107) for beneficiaries who have attained age 50, and at a frequency of once every 12 months (i.e., at least 11 months have passed following the month in which the last covered screening fecal-occult blood test was done). Screening fecal-occult blood test means a guaiac-based test for peroxidase activity, in which the beneficiary completes it by taking samples from two different sites of three consecutive stools. This screening requires a written order from the beneficiary’s attending physician. (The term “attending physician” is defined to mean a doctor of medicine or osteopathy (as defined in §1861(r) (1) of the Social Security Act) who is fully knowledgeable about the beneficiary’s medical condition, and who would be responsible for using the results of any examination performed in the overall management of the beneficiary’s specific medical problem.)

B. Screening Flexible Sigmoidoscopies (code G0104).—For claims with dates of service on or after January 1, 2002, pay for screening flexible sigmoidoscopies (Code G0104) for beneficiaries who have attained age 50 when these services were performed by a doctor of medicine or osteopathy, or by a physician assistant, nurse practitioner, or clinical nurse specialist at the frequencies noted below. For claims with dates of service prior to January 1, 2002, pay for these services under the conditions noted only when they are performed by a doctor of medicine or osteopathy.

For services furnished from January 1, 1998, through June 30, 2001, inclusive:

Once every 48 months (i.e., at least 47 months have passed following the month in which the last covered screening flexible sigmoidoscopy was done). For services furnished on or after July 1, 2001:

Once every 48 months as calculated above unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer (refer to §4180.3) and he/she has had a screening colonoscopy (code G0121) within the preceding 10 years. If such a beneficiary has had a screening colonoscopy within the preceding 10 years, then he or she can have covered a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that he/she received the screening colonoscopy (code G0121).

NOTE: If during the course of a screening flexible sigmoidoscopy a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a flexible sigmoidoscopy with biopsy or removal should be billed and paid rather than code G0104.

C. Screening Colonoscopies For Beneficiaries At High Risk Of Developing Colorectal Cancer (Code G0105).--Pay for screening colonoscopies (code G0105) when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered G0105 screening colonoscopy was performed). Refer to §4180.3 for the criteria to use in determining whether or not an individual is at high risk for developing colorectal cancer.

NOTE: 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 diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than code G0105.

D. Screening Colonoscopies Performed on Individuals Not Meeting the Criteria for Being at High-Risk for Developing Colorectal Cancer (Code G0121).--Effective for services furnished on or after July 1, 2001, pay for screening colonoscopies (code G0121) performed under the following conditions:

1. On individuals not meeting the criteria for being at high risk for developing colorectal cancer (refer to §4180.3).

2. At a frequency of once every 10 years (i.e., at least 119 months have passed following the month in which the last covered G0121 screening colonoscopy was performed).

3. If the individual would otherwise qualify to have covered a G0121 screening colonoscopy based on the above (see §4180.2.D.1 and .2) but has had a covered screening flexible sigmoidoscopy (code G0104), then he or she may have covered a G0121 screening colonoscopy only after at least 47 months have passed following the month in which the last covered G0104 flexible sigmoidoscopy was performed.

NOTE: 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 diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than code G012


E. 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



Noncovered Services.--The following noncovered HCPCS codes are used to allow claims to be billed and denied for beneficiaries who need a Medicare denial for other insurance purposes for the dates of service indicated:

A. From January 1, 1998 Through June 30, 2001, Inclusive.--Code G0121 (colorectal cancer screening; colonoscopy on an individual not meeting criteria for high risk) should be used when this procedure is performed on a beneficiary who does NOT meet the criteria for high risk. This service should be denied as noncovered because it fails to meet the requirements of the benefit for these dates of service. The beneficiary is liable for payment. Note that this code is a covered service for dates of service on or after July 1, 2001.

B. On or After January 1, 1998.--Code G0122 (colorectal cancer screening; barium enema) should be used when a screening barium enema is performed NOT as an alternative to either a screening colonoscopy (code G0105) or a screening flexible sigmoidoscopy (code G0104). This service should be denied as noncovered because it fails to meet the requirements of the benefit. The beneficiary is liable for payment.

Payment Requirements.--Code G0107 (colorectal cancer screening; fecal-occult blood test, 1-3 simultaneous determinations) must be paid at the rates established for this code under the clinical laboratory fee schedule.

Code G0104 (colorectal cancer 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 flexible sigmoidoscopy (CPT code 45330). (The same RVUs have been assigned to code G0104 as those assigned to CPT code 45330.) If during the course of a screening flexible sigmoidoscopy a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate procedure classified as a flexible sigmoidoscopy with biopsy or removal must be billed and paid rather than code G0104.

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).


• Colonoscopy (G0105 and G0121) and barium enemas (G0106 and G0120) are paid under OPPS for hospital outpatient departments and on a reasonable costs basis for CAHs or current payment methodologies for hospitals not subject to OPPS. Also colonoscopies may be done in an Ambulatory Surgical Center (ASC) and when done in an ASC the ASC rate applies. The ASC rate is the same for diagnostic and screening colonoscopies.

Screening Code Diagnostic Code G0104 45330

G0105 and G0121 45378

G0106 74280

G0120 74280 

Special Payment Instructions for TOB 13X Maryland Waiver Hospitals 

For hospitals in Maryland under the jurisdiction of the Health Services Cost Review Commission, screening colorectal services HCPCS codes G0104, G0105, G0106, 82270* (G0107*), G0120, G0121 and G0328 are paid according to the terms of the waiver, that is 94% of submitted charges minus any unmet existing deductible, co-insurance and non- covered charges. Maryland Hospitals bill TOB 13X for outpatient colorectal cancer screenings. 

Effective for services furnished on or after July 1, 2001, the following codes are used for colorectal cancer screening services:

• G0121 - Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk. Note that the description for this code has been revised to remove the term “noncovered.”

• G0122 - Colorectal cancer screening; barium enema (noncovered). 

For services furnished on or after July 1, 2001:

• Once every 48 months as calculated above unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer (refer to §60.3 of this chapter) and he/she has had a screening colonoscopy (code G0121) within the preceding 10 years. If such a beneficiary has had a screening colonoscopy within the preceding 10 years, then he or she can have covered a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that he/she received the screening colonoscopy (code G0121). 

G0121 - Colorectal Screening; Colonoscopy on Individual Not Meeting Criteria for High Risk - Applicable On and After July 1, 2001 

Effective for services furnished on or after July 1, 2001, screening colonoscopies (code G0121) performed on individuals not meeting the criteria for being at high risk for developing colorectal cancer (refer to §60.3 of this chapter) may be paid under the following conditions: 

• At a frequency of once every 10 years (i.e., 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 (code G0104), then he or she may have covered a G0121 screening colonoscopy only after at least 47 months have passed following the month in which the last covered G0104 flexible sigmoidoscopy was performed. 

NOTE: 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 diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than code G0121. 

Effective for dates of service January 1, 1998, and later, CWF will edit all colorectal screening claims for age and frequency standards. The CWF will also edit FI claims for valid procedure codes (G0104, G0105, G0106, 82270* (G0107*), G0120, G0121, G0122, and G0328) and for valid bill types. The CWF currently edits for valid HCPCS codes for carriers. 

Screening Test/Procedure  Colonoscopy-high risk 


HCPCS Code  G0105, G0121

1 comment:

  1. Great post. Thanks for sharing about CPT Code and Description. I hope that it`s very important news for of all us and also know about colorectal Cancer Screening details. If you want to know about it more you can follow this article.

    ReplyDelete

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