DM Quality Consulting, LLC

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1 DM Quality Consulting, LLC Providing an honest, compliant, quality service Medicare Part B Coverage for Screening Colorectal Cancer Testing Medicare covers colorectal screening tests in beneficiaries age 50 and older (with Part B entitlement) to help find colon or rectal cancer and/or pre-cancerous polyps so they can be removed before they turn into cancer. Coverage for these tests depends on the person s risk for colorectal cancer, when they had their last test, and whether something is found that needs to be removed during the test. Medicare provides coverage of the following colorectal cancer screening services for the early detection of colorectal cancer: Fecal Occult Blood Test (FOBT) Once every 12 months. G0328 Immunoassay-based FOBT (alternative to 82270) Guaiac-based FOBT G0464 (effective with DOS 1/1/15) - screening stool DNA test (i.e. Cologuard ) G0328 is to be submitted with the QW modifier. Diagnosis V special screening for malignant neoplasms, rectum V special screening for malignant neoplasms, colon This screening requires a written order from the beneficiary s attending physician, or effective for dates of service on or after January 27, 2014, the beneficiary s attending physician assistant, nurse practitioner, or clinical nurse specialist. Attending physician means a doctor of medicine or osteopathy 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. Medicare provides coverage of a screening FOBT (either G0328 or 82270) annually (i.e., at least 11 months have passed following the month in which the last covered screening FOBT was performed). Medicare covers the Cologuard stool DNA test once every 3 years (as of October 2014, this is the only stool DNA test covered by Medicare) for those patients that meet the following: Age 50 to 85 years, DISCLAIMER - The information in these publications are provided "as is" without any expressed or implied warranty. While all information in these documents are believed to be correct at the time of writing, these documents are for educational purposes only and do not purport to provide legal or medical advice. It is the provider's responsibility to stay current with CMS and the Medicare Administrative Contractor's (MAC) guidelines. CPT codes, descriptors, and other data only are copyright 2013 American Medical Association. All rights reserved, Applicable FARS/DFARS apply. Published 2015 DM

2 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). Flexible Sigmoidoscopy Once every 4 years, or 10 years after a previous colonoscopy. G Screening flexible sigmoidoscopy Diagnosis V special screening for malignant neoplasms, rectum V special screening for malignant neoplasms, colon Medicare provides coverage of a screening flexible sigmoidoscopy once every 4 years (i.e., at least 47 months have passed following the month in which the last covered screening flexible sigmoidoscopy was performed) for beneficiaries aged 50 and older, unless the beneficiary does not meet the high risk criteria for developing colorectal cancer and the beneficiary has had a screening colonoscopy (HCPCS code G0121) within the preceding 10 years. If the beneficiary has had a screening colonoscopy within the preceding 10 years, then the next screening flexible sigmoidoscopy will be covered only after at least 119 months have passed following the month in which the last covered screening colonoscopy (HCPCS code G0121) was performed. The flexible sigmoidoscopy must be performed by a doctor of medicine or osteopathy, nurse practitioner, physician assistant or clinical nurse specialist. If during the course of a screening flexible sigmoidoscopy a lesion or growth is detected that 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. Barium Enema (as an alternative to a covered screening flexible sigmoidoscopy or a screening colonoscopy). G0106 Barium Enema (alternative to G0104). G0120 Barium Enema (alternative to G0105). G0122 Barium Enema (non-covered). Diagnosis V special screening for malignant neoplasms, rectum V special screening for malignant neoplasms, colon Page 2 of 6

3 Medicare will cover a barium enema once every 4 years (if done instead of colonoscopy or flexible sigmoidoscopy). The screening barium enema must be ordered in writing after a determination that the test is the appropriate screening test. Colonoscopy High risk, every 24 months. Low risk, every 120 months. G0105 Colonoscopy (high risk) G0121 Colonoscopy (low risk) A screening colonoscopy must be ordered and provided by a doctor of medicine or osteopathy. High Risk Medicare will cover a 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) for beneficiaries at high risk for developing colorectal cancer. Characteristics of the High Risk Individual An individual at high risk for developing colorectal cancer has one or more of the following: 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 colorectal cancer; A personal history of adenomatous polyps; Inflammatory bowel disease, including Crohn s Disease, and ulcerative colitis. The following are examples of diagnosis codes that meet the high risk category. It is not an all-inclusive list and there could be other diagnoses that would be applicable. Contact the Medicare Administrative Contractor for specific diagnoses. Personal or Family History of Gastrointestinal Neoplasia ICD-9-CM Diagnosis Code Code Descriptor Benign neoplasm of colon Benign neoplasm of rectum and anal canal Neoplasm of uncertain behavior of stomach intestines and rectum V10.00 Personal history of malignant neoplasm of unspecified site in gastrointestinal tract V10.05 Personal history of malignant neoplasm of large intestine V10.06 Personal history of malignant neoplasm of rectum recto-sigmoid junction and anus V10.07 Personal history of malignant neoplasm of liver V12.72 Personal history of colonic polyps Page 3 of 6

4 V12.79 Personal history of other specified digestive system diseases V16.0 Family history of malignant neoplasm of gastrointestinal tract V18.51 Family history, colonic polyps Chronic Digestive Disease Conditions ICD-9-CM Diagnosis Code Code Descriptor Regional enteritis of small intestine Regional enteritis of large intestine Regional enteritis of small intestine with large intestine Regional enteritis of unspecified site Ulcerative (chronic) enterocolitis Ulcerative (chronic) ileocolitis Ulcerative (chronic) proctitis Ulcerative (chronic) proctosigmoiditis Other ulcerative colitis Ulcerative colitis, unspecified Inflammatory Bowel ICD-9-CM Diagnosis Code Code Descriptor Toxic gastroenteritis and colitis Other and unspecified noninfectious gastroenteritis and colitis Low Risk Medicare will cover a screening colonoscopy every 10 years (unless a screening flexible sigmoidoscopy has been performed and then Medicare may cover a screening colonoscopy only after at least 47 months) for patients at low risk for developing colorectal cancer. The diagnosis for a low risk colonoscopy (HCPCS G0121) is V7651. As of 2015, Medicare s cancer screening coverage information does not list virtual colonoscopy as a covered screening method for colorectal cancer. Colonoscopies that are done to evaluate specific problems, such as intestinal bleeding or anemia, are usually classified as diagnostic and not screening procedures. The same is true if the colonoscopy was done after a positive stool test (such as the FOBT) or an abnormal barium enema. If a colonoscopy leads to a biopsy or removal of a growth (polyp), the test is considered diagnostic, not screening. Interrupted and Completed Colonoscopies When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances, Medicare will pay the physician for the interrupted colonoscopy at a rate consistent with that of a flexible sigmoidoscopy as long as coverage conditions are met for the incomplete procedure. When submitting a claim for the interrupted colonoscopy, professional providers are to suffix the colonoscopy HCPCS code with modifier -53 to indicate that the procedure was interrupted. Page 4 of 6

5 When a covered colonoscopy is attempted in an ASC and is discontinued due to extenuating circumstances that threaten the well-being of the beneficiary prior to the administration of anesthesia, but after the beneficiary has been taken to the procedure room, the ASC is to suffix the colonoscopy HCPCS code with modifier -73. Payment will be reduced by 50 percent. If the colonoscopy is begun (e.g., anesthesia administered, scope inserted, incision made) but is discontinued due to extenuating circumstances that threaten the well-being of the beneficiary, the ASC is to suffix the colonoscopy HCPCS code with modifier -74. The procedure will be paid at the full amount. Medicare expects the provider to maintain adequate information in the beneficiary s medical record in the event that the Medicare Contractor needs it to document the incomplete procedure. When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to its payment methodology for this procedure as long as coverage conditions are met. This policy is applied to both screening and diagnostic colonoscopies. PT Modifier When a colorectal cancer screening test turns into a diagnostic procedure due to findings during the screening, practitioners should append the PT modifier to the diagnostic procedure code that is reported, instead of the screening code. This modifier is only appended to procedure codes in the range of to Do not use the modifier when the service began as a diagnostic procedure. The Medicare policy is that the deductible is waived for all surgical procedures (CPT code range of to 69999) furnished on the same date and in the same encounter as a colonoscopy, flexible sigmoidoscopy, or barium enema that were initiated as colorectal cancer screening services. Anesthesia Effective for claims with dates of service on or after January 1, 2015, anesthesia professionals who furnish a separately payable anesthesia service in conjunction with a screening colonoscopy (HCPCS code performed in conjunction with G0105 and G0121) shall include the following on the claim for the services that qualify for the waiver of coinsurance and deductible: Modifier 33 Preventive Services: when the primary purpose of the service is the delivery of an evidence based service in accordance with a USPSTF A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used. Page 5 of 6

6 ASC versus All-Inclusive Rate (AIR) IHS hospitals that have a valid Part B ASC PTAN, submit flexible sigmoidoscopies and colonoscopies to Medicare Part B, on the CMS claim form. Payment is made based on the ASC fee schedule. IHS hospitals without a valid Part B ASC PTAN will submit these services to Medicare Part A with type of bill 131 or 851 and 0510 revenue code. Payment is based on the AIR. Physician Services Physician services for sigmoidoscopies and colonoscopies are submitted to Medicare Part B, on the CMS-1500 claim form, with either Place of Service (POS) code 24 (ASC) or 22 (outpatient hospital). Payment is based on the physician s fee schedule. Resources CMS Internet Only Manual (IOM), Claims Processing (100-04), chapter 18, section 60: Guidance/Guidance/Manuals/Downloads/clm104c18.pdf CMS IOM, Benefit Policy Manual (100-02), chapter 15, section 280.2: Guidance/Guidance/Manuals/Downloads/bp102c15.pdf CMS IOM, National Coverage Determination (100-03), chapter 1, part 4, section 210.3: CMS Medicare Preventive Services Quick Reference Guide: echart_1.pdf Page 6 of 6