(Reproduced by permission from Medicare Focus, April, 2001.)
(Transmittal 769, CR 1552)
Effective July 1, 2001, coverage is expanded for screening colonoscopies on Medicare beneficiaries not at high risk for developing colorectal cancer according to Section 103 of the Benefits and Improvement and Protection Act for 2000.
Billing, coding, payment requirements and frequency specifications are included in the instruction from section 456 of the Medicare Hospital Manual and are given below.
Billing For Colorectal Screening
Section 4101 of the Balanced Budget Act of 1997 (P.L. 105-33) provides for Part B coverage of various colorectal examinations performed on or after January 1, 1998. Medicare will cover colorectal cancer screening tests/procedures for the early detection of colorectal cancer. Coverage of colorectal cancer screening tests includes the following procedures furnished to an individual for the early detection of colorectal cancer:
· Screening fecal-occult blood test; |
· Screening flexible sigmoidoscopy; |
· Screening colonoscopy, for high risk individuals; and |
· Screening barium enema as an alternative to screening flexible sigmoidoscopy or screening colonoscopy. |
HCPCS Coding
The following new HCPCS codes have been established for these services:
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; |
G0121 - |
Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk; and |
Note: Effective for services furnished on or after July 1, 2001, the description of this code (G0121) has been revised to remove the term “non-covered” | |
G0122 - |
Colorectal cancer screening; barium enema (non-covered). |
Coverage
The following are the coverage criteria for these new screenings:
Screening fecal-occult blood tests (code G0107) are covered at a frequency of once every 12 months for beneficiaries who have attained age 50 (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” means a doctor of medicine or osteopathy (as defined in §1861(r)(1)of the 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.)
Screening flexible sigmoidoscopies (code G0104) are covered at a frequency of once every 48 months for beneficiaries who have attained age 50 (i.e., at least 47 months have passed following the month in which the last covered screening flexible sigmoidoscopy was done). 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. This screening must be performed by a doctor of medicine or osteopathy. See below for criteria for claims furnished on or after July 1, 2001.
Screening colonoscopies (code G0105) are covered at a frequency of once every 24 months for beneficiaries at high risk for colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered screening colonoscopy was done). High risk for colorectal cancer means an individual with one or more of the following:
· |
A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyposis; |
· |
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. |
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. This screening must be performed by a doctor of medicine or osteopathy.
Section 103 of the Benefits and Improvement and Protection Act for 2000 provides for coverage of screening colonoscopies performed on or after July 1, 2001, for individuals not at high risk for colorectal cancer. Screening colonoscopies (code G0121) are covered at a frequency of once every 10 years for beneficiaries not at high risk for colorectal cancer (i.e., at least 119 months have passed following the month in which the last covered screening colonoscopy was done), or in the case of such individuals who may have had a covered screening flexible sigmoidoscopy, they have to wait another 4 years before they qualify for a covered screening colonoscopy (i.e., at least 47 months will have passed following the month in which the last covered screening flexible sigmoidoscopy was performed. In addition, this provision also amended the frequency of coverage for screening flexible sigmoidoscopies (code G0104). Screening flexible sigmoidoscopies are covered once every 48 months unless the beneficiary is not at high risk for colorectal cancer and has had a screening colonoscopy (code G0121) within the last 10 years. A beneficiary not a high risk is not covered for a screening flexible sigmoidoscopy until 119 months after the month he/she received the screening colonoscopy.
Screening barium enema examinations (codes G0106 and G0120) are covered as an alternative to either a screening sigmoidoscopy (code G0104) or a screening colonoscopy (code G0105) examination. The same frequency parameters specified in the law for screening sigmoidoscopy and screening colonoscopy apply.
In the case of an individual age 50 or over, payment may be made for a screening barium enema examination (code G0106) performed after at lease 47 months have passed following the month in which the last screening barium enema or screening flexible sigmoidoscopy was performed.
In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination 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.
The screening barium enema must be ordered in writing after a determination that the test is the appropriate screening test. 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 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.
Listed below are some examples of diagnoses that meet the high risk criteria for colorectal cancer. This is not an all inclusive list. There may be more conditions, which may be coded at the medical director’s discretion.
ICD-9-CM Codes |
Personal History: |
V10.05 Personal history of malignant neoplasm of large intestine |
V10.06 Personal history of malignant of rectum, rectosigmoid junction, and anus |
Chronic Digestive Disease Condition |
555.0 Regional enteritis of small intestine |
555.1 Regional enteritis of large intestine |
555.2 Regional enteritis of small intestine with large intestine |
555.9 Regional enteritis of unspecified site |
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 |
556.8 Other ulcerative colitis |
556.9 Ulcerative colitis, unspecified (non-specific PDX on the MCE) |
Inflammatory Bowel |
558.2 Toxic gastroenteritis and colitis |
558.9 Other and unspecified non-infectious gastroenteritis and colitis |
Non-covered Services
Two non-covered HCPCS codes have been created to assist in editing for the following:
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 a non-covered Medicare service. The beneficiary is liable for payment. |
Note: This code is a covered service for dates of service on or after July 1, 2001. |
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 a non-covered Medicare service. The beneficiary is liable for payment. Reporting of these non-covered codes will also allow claims to be billed and denied for beneficiaries who need a Medicare denial for other insurance purposes. |
Determining Frequency Standards
To determine the 11, 23, 47, and 119-month periods, start your count beginning with the month after the month in which a previous test/procedure was performed.
Example: |
The beneficiary received a fecal-occult blood test in January 1998. Start your count beginning with February 1998. The beneficiary is eligible to receive another blood test in January 1999 (the month after 11 full months have passed). |
Billing Requirements for Intermediaries
Intermediaries will follow the general bill review instructions in §3604 of the Medicare Intermediary Manual, Part 3. Hospital should bill on Form HCFA-1450 using bill type 13x, 83x, or 85X. In addition, the hospital bills revenue codes and HCPCS codes as follows:
Screening Test Procedure |
Revenue Code |
HCPCS Code |
Occult blood test |
30X |
G0107 |
Barium enema |
32X |
G0106, G0120, G0122 |
Flexible sigmoidoscopy |
* |
G0104 |
Colonoscopy-high risk |
* |
G0105, G0121 |
*The appropriate revenue code when reporting any other surgical procedure.
Payment Requirements for Intermediaries
Payment for hospital outpatient departments will be as follows:
Payment for screening flexible sigmoidoscopy (code G0104) is under the outpatient prospective payment system (OPPS) for hospital departments and on a reasonable cost basis for critical access hospitals (CAHs); and payment for screening colonoscopy (code G0105) and payment for screening barium enema (code G0106 or G0120) is under OPPS for hospital outpatient departments and on a reasonable cost basis for CAHs. There is no beneficiary liability for CAHs.
For screening fecal-occult blood test (code G0107) payment is under the clinical diagnostic laboratory fee schedule using payment amount associated with G0107 and on a reasonable cost basis for CAHs.
Special Billing Instructions for Hospital Inpatients
When these tests/procedures are provided to inpatients of a hospital, they are covered under this benefit. However, the provider bills on bill type 13X using the discharge date of the hospital stay to avoid editing in the Common Working File (CWF) as a result of the hospital bundling rules.
Common Working Files (CWF) Edits
Effective for dates of service January 1, 1998, and later, CWF will edit all claims for colorectal screening for age and frequency standards. CWF will also edit fiscal intermediary claims for valid procedure codes (G0104, G0105, G0106, G0107, G0120, G0121, and G0122) and for valid bill types. CWF currently edits for valid HCPCS codes for carriers.
Post Office Boxes for Medical Records
Part A
To assure that all medical records are received and processed timely, please use the following Post Office Boxes when submitting documentation. Be sure to include the copy of your Medicare Part A additional development request letter as a cover sheet. When submitting initial claims electronically, it would be to your advantage to submit any additional documentation only as Medicare requests it. Send records for Part A to:
Medicare Part A Medical Records
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If the claim is denied, you have the right to an appeal. Any information not initially submitted must be attached to justify medical necessity. T hese requests for reconsideration and review must be sent to:
Medicare Part A Appeals
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