Wednesday, October 21, 2015

CPT CODE G0464 COVERED DX AND benefit period - denial reason

CR 9115 instructs the MACs that effective for claims with dates of service on or after October 9, 2014, Medicare will recognize new Healthcare Common Procedure Coding System (HCPCS) code G0464, (Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (for example, KRAS, NDRG4 and BMP3)) as a covered service.

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

Go – what you need to do
Make sure that your billing staff are aware of these changes.


October 9, 2014, MACs will recognize the new HCPCS code G0464 as a covered service. Be aware that claims for HCPCS code G0464 must also include ICD-9 diagnosis codes V76.41 and V76.51. Once ICD-10 is implemented, the claim must reflect ICD-10 diagnosis codes Z12.12 and Z12.11.


MACs will only pay for HCPCS code G0464 when it is submitted on types of bill (TOB) 13x hospital outpatient departments), 14x (hospital non-patient laboratories), or
85x (critical access hospitals). Payments will be made on TOB 13x and 14x based on the clinical laboratory fee schedule (CLFS). Payment for TOB 85x will be based on
reasonable cost.

Effective for dates of service on or after October 9, 2014, Medicare Part B will cover the CologuardTM test once every three years for Medicare beneficiaries that meet all of the following criteria:

 Age 50 to 85 years;
 Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test); and
 At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis; no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).

There is no coinsurance or deductible for tests paid under the CLFS. Therefore, there is no coinsurance or deductible for HCPCS code G0464.

Medicare will pay for this service for eligible beneficiaries only once every three years. Next eligible dates will be displayed on all common working file (CWF) provider query screens. Subsequent claim lines for HCPCS code G0464 received in the same three-year period will be denied using the following:

 Claim adjustment reason code (CARC) 119 – “Benefit maximum for this time period has been reached;”

 Remittance advice remarks code (RARC) N386 – “This decision was based on a national coverage determination (NCD). An NCD provides a coverage determination as to whether a particular item or service is covered. A copy of this policy is available at www.cms.gov/mcd/search.asp. If you do not have web access, you may contact the contractor to request a copy of the NCD;” and

 Group code CO assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed advance beneficiary notice (ABN)
is on file.

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