00810 – Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum

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 (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection)

G0104 – Flexible Sigmoidoscopy

G0105 – Colonoscopy (high risk)

G0106 – Barium Enema (alternative to G0104)

G0120 – Barium Enema (alternative to G0105)

G0121 – Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

G0328 – Fecal Occult Blood Test (FOBT), immunoassay, 1-3 simultaneous

G0464 – Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3)

No specific diagnosis code

Contact local Medicare Administrative Contractor (MAC) for guidance

For Cologuard Multitarget Stool DNA (sDNA) Test, use Z12.11 and Z12.12

For colorectal cancer screening using Cologuard™—a Multitarget Stool DNA (sDNA) Test:

All Medicare beneficiaries:

• Aged 50 to 85 years;
• Asymptomatic; and
• At average risk of developing colorectal cancer, meaning they have no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis.

For screening colonoscopies, FOBTs, flexible sigmoidoscopies, and barium enemas:

All Medicare beneficiaries:

• Aged 50 and older who are at normal risk of developing colorectal cancer; or
• At high risk of developing colorectal cancer

“High risk for developing colorectal cancer” is defined in the Code of Federal Regulations (CFR) at 42 CFR 410.37(a)(3).

NOTE: For coverage of screening colonoscopies, there is no age limitation.

Normal Risk:

• Cologuard™ Multitarget Stool DNA (sDNA) Test: once every 3 years;
• Screening FOBT: every year;
• Screening flexible sigmoidoscopy: once every 4 years (unless a screening colonoscopy has been performed and then Medicare may cover a screening flexible sigmoidoscopy only after at least 119 months);
• Screening colonoscopy: every 10 years (unless a screening flexible sigmoidoscopy has been performed and then Medicare may cover a screening colonoscopy only after 47 months); and
• Screening barium enema (as an alternative to covered screening flexible sigmoidoscopy)

High Risk:

• Screening FOBT: every year;
• Screening flexible sigmoidoscopy: once every 4 years;
• 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); and
• Screening barium enema (as an alternative to covered screening flexible sigmoidoscopy or colonoscopy)

You pay nothing for the fecal occult blood test, if you get a written referral from your doctor, physician assistant, nurse practitioner, or clinical nurse specialist. You pay nothing for the flexible sigmoidoscopy or screening colonoscopy if your doctor accepts assignment.

Note: If a polyp or other tissue is found and removed during the colonoscopy, you may have to pay 20% of the Medicare-approved amount for the doctor’s services and a copayment in a hospital outpatient setting.

For barium enemas, you pay 20% of the Medicare-approved amount for the doctor’s services. The Part B deductible doesn’t apply. If it’s done in a hospital outpatient setting, you pay a copayment.

81528, 82270, G0104, G0105, G0121, and G0328, and G0464:

• Copayment/coinsurance waived
• Deductible waived

Append modifier - 33 to the anesthesia CPT code 00810 when you furnish a separately payable anesthesia service in conjunction with a screening colonoscopy (G0105 and G0121) to waive beneficiary copayment/coinsurance and deductible.

G0106 and G0120:

• Copayment/coinsurance waived
• Deductible waived

No deductible for all surgical procedures (CPT code range of 10000 to 69999) furnished on the same date and in the same encounter as a screening colonoscopy, flexible sigmoidoscopy, or barium enema initiated as colorectal cancer screening services.

Append modifier - PT to CPT code in the surgical range of 10000 to 69999 in this scenario.