HCPCS Codes, Frequency Requirements, and Age Requirements

60.2 - HCPCS Codes, Frequency Requirements, and Age Requirements (Rev. 12299; Issued:10-12-23; Effective:01-01-23; Implementation:11-13-23) Effective for services furnished on or after January 1, 1998, the following codes are used for colorectal cancer screening services: • CPT 82270* (HCPCS G0107*) - Colorectal cancer screening; fecal-occult blood tests, 1-3 simultaneous determinations; • HCPCS G0104 - Colorectal cancer screening; flexible sigmoidoscopy; • HCPCS G0105 - Colorectal cancer screening; colonoscopy on individual at high risk; • HCPCS G0106 - Colorectal cancer screening; barium enema; as an alternative to HCPCS G0104, screening sigmoidoscopy; • HCPCS G0120 - Colorectal cancer screening; barium enema; as an alternative to HCPCS G0105, screening colonoscopy. Effective for services furnished on or after July 1, 2001, the following codes are added for colorectal cancer screening services: • HCPCS G0121 - Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk. • HCPCS G0122 - Colorectal cancer screening; barium enema (non-covered). Effective for services furnished on or after January 1, 2004, the following code is added for colorectal cancer screening services as an alternative to CPT 82270* (HCPCS G0107*): • HCPCS G0328 - Colorectal cancer screening; immunoassay, fecal-occult blood test, 1-3 simultaneous determinations. Effective for services furnished on or after October 9, 2014, the following code is added for colorectal cancer screening services: • HCPCS G0464 - Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3). Effective January 1, 2016, HCPCS G0464 is discontinued and replaced with CPT 81528. Effective for services furnished on or after January 19, 2021, the following code is added for colorectal cancer services: • HCPCS G0327 - Colorectal cancer screening; blood-based biomarker Colon ca scrn;bld- bsd biomrk Effective for claims with dates of service on or after January 1, 2023, the frequency limitations for screening colonoscopy (HCPCS codes G0105, G0121) shall not apply when the screening colonoscopy follows a positive result from a non-invasive stool-based test (HCPCS codes 82270, G0328 and 81528). This scenario is identified when the furnishing practitioner submits the screening colonoscopy claim with the KX modifier. See 42 CFR 410.37(k). *NOTE: For claims with dates of service prior to January 1, 2007, physicians, suppliers, and providers report HCPCS G0107. Effective January 1, 2007, HCPCS G0107 is discontinued and replaced with CPT 82270. G0104 – Colorectal Cancer Screening; Flexible Sigmoidoscopy Screening flexible sigmoidoscopies (HCPCS G0104) may be paid for beneficiaries who have attained age 50, when performed by a doctor of medicine or osteopathy at the frequencies noted below. For claims with dates of service on or after January 1, 2002, A/B MACs (A) and (B) pay for screening flexible sigmoidoscopies (HCPCS G0104) for beneficiaries who have attained age 50 when these services were performed by a doctor of medicine or osteopathy, or by a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS) (as defined in §1861(aa)(5) of the Social Security Act (the Act) and in the Code of Federal Regulations (CFR) at 42 CFR 410.74, 410.75, and 410.76) at the frequencies noted above. For claims with dates of service prior to January 1, 2002, Medicare Administrative Contractors (MACs) pay for these services under the conditions noted only when a doctor of medicine or osteopathy performs them. For services furnished from January 1, 1998, through June 30, 2001, inclusive: • Once every 48 months (i.e., at least 47 months have passed following the month in which the last covered screening flexible sigmoidoscopy was performed). For services furnished on or after July 1, 2001: • Once every 48 months as calculated above unless the beneficiary does not meet the criteria for high risk of developing colorectal cancer (refer to §60.3 of this chapter) and he/she has had a screening colonoscopy (HCPCS G0121) within the preceding 10 years. If such a beneficiary has had a screening colonoscopy within the preceding 10 years, then he or she can have covered a screening flexible sigmoidoscopy only after at least 119 months have passed following the month that he/she received the screening colonoscopy (HCPCS G0121). Effective for claims with dates of service on or after January 1, 2023, the minimum age for screening flexible sigmoidoscopy is reduced to 45 years and older. NOTE: 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 along with modifier -PT should be billed and paid rather than HCPCS G0104. HCPCS G0105 – Colorectal Cancer; Colonoscopy on Individual at High Risk Screening colonoscopies (HCPCS code G0105) may be paid when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered HCPCS G0105 screening colonoscopy was performed). Refer to §60.3 of this chapter for the criteria to use in determining whether or not an individual is at high risk for developing colorectal cancer. NOTE: 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 along with modifier -PT should be billed and paid rather than HCPCS G0105. A. Colonoscopy Cannot be Completed Because of Extenuating Circumstances 1. A/B MACs (A) When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances, Medicare will pay for the interrupted colonoscopy as long as the coverage conditions are met for the incomplete procedure. However, the frequency standards associated with screening colonoscopies will not be applied by the Common Working File (CWF). 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, and the frequency standards will be applied by CWF. This policy is applied to both screening and diagnostic colonoscopies. When submitting a facility claim for the interrupted colonoscopy, providers are to suffix the colonoscopy. Use of HCPCS codes with a modifier of -73 or -74 is appropriate to indicate that the procedure was interrupted. Payment for covered incomplete screening colonoscopies shall be consistent with payment methodologies currently in place for complete screening colonoscopies, including those contained in 42 CFR 419.44(b). In situations where a CAH has elected payment Method II for CAH patients, payment shall be consistent with payment methodologies currently in place as outlined in chapter 3 of this manual. As such, instruct CAHs that elect Method II payment to use modifier -53 to identify an incomplete screening colonoscopy (physician professional service(s) billed in revenue code 096X, 097X, and/or 098X). Such CAHs will also bill the technical or facility component of the interrupted colonoscopy in revenue code 075X (or other appropriate revenue code) using the -73 or -74 modifier as appropriate. Note that Medicare would expect the provider to maintain adequate information in the patient’s medical record in case it is needed by the A/B MAC (A) to document the incomplete procedure. 2. A/B MACs (B) When a covered colonoscopy is attempted but cannot be completed because of extenuating circumstances (see chapter 12, section 30.1), Medicare will pay for the interrupted colonoscopy at a rate that is calculated using one-half the value of the inputs for the codes. The MPFS database has specific values for codes 44388-53, 45378-53, G0105-53 and G0121-53. 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. When submitting a claim for the interrupted colonoscopy, professional providers are to suffix the colonoscopy code with a modifier of -53 to indicate that the procedure was interrupted. When submitting a claim for the facility fee associated with this procedure, ASCs) are to suffix the colonoscopy code with modifier -73 or -74 as appropriate. Payment for covered screening colonoscopies, including that for the associated ASC facility fee when applicable, shall be consistent with payment for diagnostic colonoscopies, whether the procedure is complete or incomplete. Note that Medicare would expect the provider to maintain adequate information in the patient’s medical record in case it is needed by the A/B MAC (B) to document the incomplete procedure. HCPCS G0106 – Colorectal Cancer Screening; Barium Enema; as an Alternative to HCPCS G0104, Screening Sigmoidoscopy Screening barium enema examinations may be paid as an alternative to a screening sigmoidoscopy (HCPCS G0104). The same frequency parameters for screening sigmoidoscopies (see those codes above) apply. In the case of an individual aged 50 or over, payment may be made for a screening barium enema examination (HCPCS G0106) performed after at least 47 months have passed following the month in which the last screening barium enema or screening flexible sigmoidoscopy was performed. For example, the beneficiary received a screening barium enema examination as an alternative to a screening flexible sigmoidoscopy in January 1999. Start count beginning February 1999. The beneficiary is eligible for another screening barium enema in January 2003. The screening barium enema must be ordered in writing after a determination that the test is the appropriate screening test. Generally, it is expected that this will be a screening double contrast enema unless the individual is unable to withstand such an exam. 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 a screening flexible sigmoidoscopy 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. Effective for claims with dates of service on or after January 1, 2023, the minimum age for Colorectal Cancer Screening; Barium Enema; as an Alternative to Screening Sigmoidoscopy is reduced to 45 years and older. CPT 82270* (HCPCS G0107*) – Colorectal Cancer Screening; FOBT, 1-3 Simultaneous Determinations Effective for services furnished on or after January 1, 1998, screening FOBT (code 82270* (HCPCS G0107*) may be paid for beneficiaries who have attained age 50, and at a frequency of once every 12 months (i.e., at least 11 months have passed following the month in which the last covered screening FOBT was performed). This screening FOBT 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, or effective for dates of service on or after January 27, 2014, the beneficiary’s attending physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). (The term “attending physician” is defined to mean 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.) Effective for services furnished on or after January 1, 2004, payment may be made for an immunoassay-based FOBT (HCPCS G0328, described below) as an alternative to the guaiac- based FOBT, CPT 82270* (HCPCS G0107*). Medicare will pay for only one covered FOBT per year, either CPT 82270* (HCPCS G0107*) or HCPCS G0328, but not both. *NOTE: For claims with dates of service prior to January 1, 2007, physicians, suppliers, and providers report HCPCS G0107. Effective January 1, 2007, HCPCS G0107 is discontinued and replaced with CPT 82270. Effective for claims with dates of service on or after January 1, 2023, the minimum age for Colorectal Cancer Screening; FOBT, 1-3 Simultaneous Determinations is reduced to 45 years and older. HCPCS G0328 – Colorectal Cancer Screening; Immunoassay, FOBT, 1-3 Simultaneous Determinations Effective for services furnished on or after January 1, 2004, screening FOBT, (HCPCS G0328) may be paid as an alternative to CPT 82270* (HCPCS G0107*) for beneficiaries who have attained age 50. Medicare will pay for a covered FOBT (either CPT 82270* (HCPCS G0107*) or HCPCS G0328, but not both) at a frequency of once every 12 months (i.e., at least 11 months have passed following the month in which the last covered screening FOBT was performed). Screening FOBT, immunoassay, includes the use of a spatula to collect the appropriate number of samples or the use of a special brush for the collection of samples, as determined by the individual manufacturer’s instructions. This screening requires a written order from the beneficiary’s attending physician, or effective for claims with dates of service on or after January 27, 2014, the beneficiary’s attending PA, NP, or CNS. (The term “attending physician” is defined to mean 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.) Effective for claims with dates of service on or after January 1, 2023, the minimum age for Colorectal Cancer Screening; Immunoassay, FOBT, 1-3 Simultaneous Determinations is reduced to 45 years and older. HCPCS G0120 – Colorectal Cancer Screening; Barium Enema; as an Alternative to HCPCS G0105, Screening Colonoscopy Screening barium enema examinations may be paid as an alternative to a screening colonoscopy (HCPCS G0105) examination. The same frequency parameters for screening colonoscopies (see those codes above) apply. In the case of an individual who is at high risk for colorectal cancer, payment may be made for a screening barium enema examination (HCPCS G0120) 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. For example, a beneficiary at high risk for developing colorectal cancer received a screening barium enema examination (HCPCS G0120) as an alternative to a screening colonoscopy (HCPCS G0105) in January 2000. Start counts beginning February 2000. The beneficiary is eligible for another screening barium enema examination (HCPCS G0120) in January 2002. The screening barium enema must be ordered in writing after a determination that the test is the appropriate screening test. Generally, it is expected that this will be a screening double contrast enema unless the individual is unable to withstand such an exam. 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 a screening colonoscopy, 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. Effective for claims with dates of service on or after January 1, 2023, the minimum age for Colorectal Cancer Screening; Barium Enema; as an Alternative to Screening Colonoscopy is reduced to 45 years and older. HCPCS G0121 – Colorectal Cancer Screening; Colonoscopy on Individual Not Meeting Criteria for High Risk - Applicable On and After July 1, 2001 Effective for services furnished on or after July 1, 2001, screening colonoscopies (HCPCS G0121) performed on individuals not meeting the criteria for being at high risk for developing colorectal cancer (refer to §60.3 of this chapter) may be paid under the following conditions: • At a frequency of once every 10 years (i.e., at least 119 months have passed following the month in which the last covered HCPCS G0121 screening colonoscopy was performed.) • If the individual would otherwise qualify to have covered a HCPCS G0121 screening colonoscopy based on the above but has had a covered screening flexible sigmoidoscopy (HCPCS G0104), then he or she may have covered a HCPCS G0121 screening colonoscopy only after at least 47 months have passed following the month in which the last covered HCPCS G0104 flexible sigmoidoscopy was performed. NOTE: 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 along with modifier -PT should be billed and paid rather than HCPCS G0121. HCPCS G0464 (Replaced with CPT 81528) - Multitarget sDNA Colorectal Cancer Screening Test - CologuardTM Effective for dates of service on or after October 9, 2014, colorectal cancer screening using the CologuardTM multi-target sDNA test (G0464/81528) is covered once every 3 years for Medicare beneficiaries that meet all of the following criteria: • Ages 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 FOBT 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 cancer adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer). Effective for claims with dates of service on or after October 9, 2014, providers shall report at least ONE of the following diagnosis codes when submitting claims for the Cologuard™ multi- target sDNA test: Z12.11 Encounter for screening for malignant neoplasm of colon, OR, Z12.12 Encounter for screening for malignant neoplasm of rectum NOTE: Effective January 1, 2016, HCPCS G0464 is discontinued and replaced with CPT 81528 Effective for claims with dates of service on or after January 1, 2023, the minimum age for Multitarget sDNA Colorectal Cancer Screening Test - CologuardTM is reduced to 45 years and older. HCPCS G0327- Colorectal Cancer Screening - Blood-based Biomarker Tests Blood-based DNA testing detects molecular markers of altered DNA that are contained in the cells shed into the lumen of the large bowel by colorectal cancer and pre-malignant colorectal epithelial neoplasia. Effective for dates of service on or after January 19, 2021, a blood-based biomarker test is covered as an appropriate colorectal cancer screening test once every 3 years for Medicare beneficiaries when performed in a CLIA-certified laboratory, when ordered by a treating physician and when all of the following requirements are met: The patient is: • age 50-85 years, and, • asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac FOBT 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 cancer or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer). The blood-based biomarker screening test must have all of the following: • FDA market authorization with an indication for colorectal cancer screening; and, • proven test performance characteristics for a blood-based screening test with both sensitivity greater than or equal to 74% and specificity greater than or equal to 90% in the detection of colorectal cancer compared to the recognized standard (accepted as colonoscopy at this time), as minimal threshold levels, based on the pivotal studies included in the FDA labeling. Effective for claims with dates of service on or after January 19, 2021, providers shall report at least ONE of the following diagnosis codes when submitting claims for the Blood-based Biomarker test HCPCS G0327: Z12.11 Encounter for screening for malignant neoplasm of colon, OR, Z12.12 Encounter for screening for malignant neoplasm of rectum Effective for claims with dates of service on or after January 1, 2023, the minimum age for Colorectal Cancer Screening - Blood-based Biomarker Tests is reduced to 45 years and older. HCPCS G0122 – Colorectal Cancer Screening; Barium Enema The code is not covered by Medicare.