Last Modified: 5/13/2024
Location: FL, PR, USVI
Business: Part B
Effective with dates of service on and after January 1, 2023:
• Reduction in coinsurance when a CRC screening becomes diagnostic
• Minimum age for CRC screening tests lowered from 50 to 45
• CRC screening tests include a follow-up screening colonoscopy if a non-invasive stool-based test returns a positive result.
• Report the KX modifier when CRC screening tests include a screening colonoscopy (HCPCS codes G0105, G0121) after a non-invasive stool-based test (HCPCS codes 82270, G0328 and 81528).
• The KX modifier needs to be reported on the screening colonoscopy claim.
• Deductible and coinsurance do not apply to non-invasive stool-based tests nor the screening colonoscopy because both tests are specified preventive screening services.
CRC screening using MT-sDNA and blood-based biomarker tests
• Available for patients with Medicare Part B who meet these criteria:
• Aged 45–85 years
• Asymptomatic
• At average CRC risk
Screening colonoscopies, fecal occult blood tests (FOBTs), flexible sigmoidoscopies, and barium enemas:
• Available for patients with Medicare Part B who meet at least one of the following criteria:
• At normal CRC risk
• No minimum age requirement for screening colonoscopies
• Aged 45 and older for other screenings
• At high CRC risk
• No minimum age requirement
• 00812 -- Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy
• 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 provided three cards or single triple card for consecutive collection).
• 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
• G0327 -- Colorectal cancer screening; blood-based biomarker
• G0328 -- Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous
Deductible, coinsurance and modifiers
For codes 00812, 81528, 82270, G0104, G0105, G0121, G0327 and G0328, deductible and coinsurance are waived.
For codes G0106 and G0120, deductible is waived, but coinsurance applies.
No deductible applies for all surgical procedures (CPT code range 10000-69999) furnished on the same date and in the same encounter as a screening colonoscopy, flexible sigmoidoscopy, or barium enema initiated as CRC screening services.
Append modifier -PT to the surgical code for all surgical procedures (CPT code range 10000-69999) furnished on the same date and in the same encounter as a screening colonoscopy, flexible sigmoidoscopy, or barium enema initiated as CRC screening services,
To indicate a screening colorectal cancer procedure (codes G0104, G0105, or G0121) has become a diagnostic or therapeutic service, add modifier -PT to at least one code on the claim, submitted on the line item with codes 10000-69999, G0500, 00811, or 99153 for a diagnostic colonoscopy, diagnostic flexible sigmoidoscopy, or other procedure.
• For dates of service from January 1, 2023-December 31, 2026, the deductible and a reduced coinsurance of 15% will apply for all procedure codes identified here performed on that date of service and billed on the same claim.
Effective for claims with dates of service on or after January 1, 2023, CRC screening tests include a screening colonoscopy (HCPCS codes G0105, G0121) after a non-invasive stool-based test (HCPCS codes 82270, G0328 and 81528). This scenario shall be identified by including the -KX modifier on the screening colonoscopy claim.
• Deductible and coinsurance do not apply to the non-invasive stool-based tests nor the screening colonoscopy because both tests are specified preventive screening services.
Follow-up service
Effective January 1, 2023, if the patient initially has a non-invasive stool-based screening test (FOBT or MT-sDNA test) and receives a positive result, Medicare also covers a follow-up colonoscopy as a screening test. The patient pays nothing for the screening test(s) if their doctor or other qualified health care provider accepts assignment. Frequency limitations described for screening colonoscopy in the charts below do not apply in this scenario.
For beneficiaries not meeting criteria for high risk:
Service |
Timeframe |
MT-sDNA and blood-based biomarker tests |
Once every 3 years |
Screening FOBT |
Once every 12 months |
Screening flexible sigmoidoscopy |
Once every 48 months (unless the beneficiary does not meet high-risk colorectal cancer criteria and had a screening colonoscopy within the preceding 10 years, in which case Medicare may cover a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that the beneficiary received the screening colonoscopy). |
Screening colonoscopy |
Once every 120 months (10 years) or 48 months after a previous sigmoidoscopy. |
Screening barium enema (when used instead of a flexible sigmoidoscopy or colonoscopy) |
Once every 48 months |
For beneficiaries at high risk:
Service |
Timeframe |
Screening FOBT |
Once every 12 months |
Screening flexible colonoscopy |
Once every 48 months |
Screening colonoscopy |
Once every 24 months (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 (when used instead of a flexible sigmoidoscopy or colonoscopy) |
Once every 24 months |
• Append modifier -33 (Preventive service) to the anesthesia CPT code 00812 when you furnish a separately payable anesthesia service in conjunction with a screening colonoscopy (codes G0105 and G0121) to waive Medicare beneficiary coinsurance and deductible.
• When a screening colonoscopy becomes a diagnostic colonoscopy, report anesthesia services with CPT code 00811 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified) with only the -PT modifier, and only the deductible will be waived. Report this in addition to CPT code 00812.
• Coinsurance and deductible are waived for moderate sedation services (reported with codes G0500 or 99153) when furnished in conjunction with and in support of a screening colonoscopy service and when reported with modifier -33.
• When a screening colonoscopy becomes a diagnostic colonoscopy, moderate sedation services (codes G0500 or 99153) are reported with only the -PT modifier; only the deductible is waived.
Source: CR 13017
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