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Colorectal Cancer Screening

What’s New

Effective with dates of service on and after June 8, 2026:

  • Non-invasive biomarker tests are appropriate for CRC screening once every three years based on the following patient criteria:
    • Patient aged 45-85
    • Asymptomatic
    • At average risk
    • Active Medicare Part B coverage
  • Before ordering the test and using results for patient management, provider must explain how the test performs and why a follow-up colonoscopy is important if test result is positive
  • The test must:
    • Be Food and Drug Administration (FDA) market-authorized and indicated for CRC screening
    • Meet FDA-required post-approval study requirements in the safety and effectiveness data to continue coverage
    • Be processed by Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory
    • Demonstrate performance characteristics in detecting CRC compared to the recognized standard (currently accepted as colonoscopy) that meet either of the test performance criteria in the table

Test performance guidelines:

Performance Characteristic Test Performance Criteria 1 Test Performance Criteria 2
Sensitivity for CRC > than or = to 90% > than or = to 79%
Specificity for CRC > than or = to 87% > than or = to 90%

 

Medicare will accept and reimburse for the CRC screening test using CPT code 0421U. Deductible and coinsurance will be waived.

Medicare Coverage

Colorectal cancer screening using multitarget stool DNA (MT-sDNA) and blood-based biomarker tests:

  • Patients with Medicare Part B who meet these criteria:
    • Aged 45-85 years
    • Asymptomatic
    • At average colorectal cancer risk

Screening colonoscopies, fecal occult blood tests (FOBTs), flexible sigmoidoscopies, and computed tomography (CT) colonography:

  • Patients with Medicare Part B who meet at least one of these criteria:

HCPCS/CPT Codes

00811 – Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; not otherwise specified

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 was provided 3 cards or single triple card for consecutive collection)

0464U – Oncology (colorectal) screening, quantitative real-time target and signal amplification, methylated DNA markers, including LASS4, LRRC4 and PPP2R5C, a reference marker ZDHHC1, and a protein marker (fecal hemoglobin), utilizing stool, algorithm reported as a positive or negative result 

0537U – Oncology (colorectal cancer), analysis of cell-free DNA for epigenomic patterns, next-generation sequencing, >2500 differentially methylated regions (DMRs), plasma, algorithm reported as positive or negative 

G0104 – Colorectal cancer screening; flexible sigmoidoscopy

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

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

Coinsurance and Deductible

No coinsurance, or deductible is charged for these services.

No deductible applies for all surgical procedures (CPT code range of 10000-69999) furnished on the same date and in the same encounter as a screening colonoscopy, flexible sigmoidoscopy, or CT colonography initiated as colorectal cancer screening services. Append modifier PT (Colorectal cancer screening test; converted to diagnostic test or other procedure) to CPT code in the surgical range of 10000-69999 in this scenario.

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 1 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. The deductible is waived and, for dates of service from January 1, 2023-December 31, 2026, a reduced coinsurance of 15% will apply for all procedure codes identified here that are performed on that date of service and billed on the same claim.

If the patient initially has a non-invasive screening test (FOBT or MT-sDNA test) and receives a positive result, Medicare also covers a follow-up colonoscopy as a screening test. This scenario shall be identified by including the modifier KX (requirements in the specified medical policy have been met) on the screening colonoscopy claim. The patient pays nothing for the screening test(s) if their doctor or other qualified health care provider accepts assignment. The frequency limitations described for screening colonoscopy in the charts below that do not apply in this scenario.

Frequency

For beneficiaries not meeting criteria for high risk:

Service Timeframe
MTs-DNA and blood-based biomarker tests Once every three 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 past 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
CT colonography

At least 59 months must have elapsed since the month the patient last received a screening CT colonoscopy

At least 47 months have elapsed since the month the patient received their last screening flexible sigmoidoscopy or screening colonoscopy

 

For beneficiaries at high risk:

Service Timeframe
Screening FOBT Once every 12 months
Screening flexible sigmoidoscopy 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)
CT colonography At least 23 months since the month the patient received their last screening CT colonography or screening colonoscopy

Additional Information

Anesthesia services furnished in conjunction with and in support of a screening colonoscopy are reported with CPT code 00812 and coinsurance and deductible are waived.

When a screening colonoscopy becomes a diagnostic colonoscopy, anesthesia services are reported with CPT code 00811 and with the PT modifier; only the deductible is waived.

Coinsurance and deductible are waived for moderate sedation services (reported with 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 (G0500 or 99153) are reported with only the PT modifier; only the deductible is waived.

 

References