"CPT Copyright 2016 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.""

Featured Post

2018 New CPT codes

00731  Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum; not otherwise specified ...

COLORECTAL CANCER SCREENING - MEDICARE BENEFITS


Medicare currently covers:

A. Annual screening fecal-occult blood test (FOBT) guaiac or immunoassay
B. Screening flexible sigmoidoscopy every 4 years;
C. Screening colonoscopy, every 2 years for persons at high risk or every 10 years for persons at average risk.
D. Screening barium enema (G0106 and G0120) every 4 years as an alternative to a screening flexible sigmoidoscopy or every 2 years as an alternative to a screening colonoscopy for persons of high risk for colorectal cancer.

What is Screening Fecal-occult blood test?

Screening fecal-occult blood test 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.

Limitations:

A screening fecal-occult blood tests (82270) or screening immunoassay fecal-occult blood test (G0328) is covered at a frequency of once every 12 months for beneficiaries who have attained age 50 (at least 11 months have passed following the month in which the last covered screening fecaloccult blood test was done).

Requirements:

Screening fecal-occult blood test requires a written order from the attending physician. The attending physician is defined as a doctor of medicine or osteopathy who is fully knowledgeable about the beneficiary’s medical condition, and would be responsible for using the results of any examination performed in the overall management of the beneficiary’s specific medical problem.

What is screening flexible sigmoidoscopy?

Screening flexible sigmoidoscopy is an important screening procedure to detect early changes in the distal colon. The 60-cm flexible sigmoidoscope provides excellent visualization of sigmoid and descending colon with minimal discomfort to patients. To date, no randomized, controlled trials have shown that flexible sigmoidoscopy reduces the mortality rate associated with colorectal cancer. Sigmoidoscopy is most commonly used to screen asymptomatic patients for precancerous changes and malignancies. Signs and symptoms such as diarrhea, proctitis and rectal pain can be evaluated by flexible sigmoidoscopy.

Limitations:

Screening flexible sigmoidoscopies (G0104) are covered at a frequency of once every 48 months for beneficiaries who have attained age 50 (ie. at least 47 months have passed following the month in which the last covered screening flexible sigmoidoscopy was done).

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 should be billed (ie. 45331, 45332).

Who can perform screening flexible sigmoidoscopy?

Screening flexible sigmoidoscopy procedure would be paid, when a doctor of medicine, osteopathy, physician assistant (PA), Nurse Practitioner (NP) or Clinical Nurse Specialist (CNS), performs it.

What is screening colonoscopy?

Screening Colonoscopy is an investigation or testing the patients with a scope who currently has no symptoms but are at high risk for colon / rectal cancer and / or any other abnormality of the Intestinal tract. A screening colonoscopy is used to identify and remove polyps in its precancerous stage before it develops to a cancer.

Limitations:

Coverage Limitations for High Risk patients:

Screening colonoscopies (G0105) are covered at a frequency of once every 24 months for beneficiaries at high risk for colorectal cancer (ie. at least 23 months have passed following the month in which the last covered screening colonoscopy was performed).

High risk for colorectal cancer is an individual with one or more of the following:

1. A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp (V16.0, V19.8);
2. A family history of familial adenomatous polyposis (V19.8);
a family history of hereditary nonpolyposis colorectal cancer (V16.0 & V19.8)
3. A personal history of adenomatous polyps (V12.72); or
a personal history of malignant neoplasm of the large intestine (V10.05)
a personal history of colorectal cancer (V10.06); or
a personal history of gastrointestinal cancer (V10.00, V10.03, V10.04, V10.07)
Inflammatory bowel disease, including Crohn’s Disease, and ulcerative colitis (555.0-555.2, 555.9-556.3, 556.8, 556.9, 558.2, 558.9).

Coverage Limitations for patients who are not at risk:

On individuals not meeting the criteria for being at high risk for developing colorectal cancer Screening Colonoscopies are covered at a frequency of once every 10 years (i.e., at least 119 months have passed following the month in which the last covered G0121 screening colonoscopy was performed.)

Who can perform Screening colonoscopy?

A doctor of medicine or osteopathy must perform this screening.

Coverage Limitations for Screening Flexible Sigmoidoscopy and Screening colonoscopy:

If the individual would otherwise qualify to have covered a G0121 screening colonoscopy, based on the above, but has had a covered screening flexible sigmoidoscopy (code G0104), then he or she may have covered a G0121 screening colonoscopy only after at least 47 months have passed following the month in which the last covered G0104 flexible sigmoidoscopy was performed.

What is screening barium enema?

A barium enema, or lower gastrointestinal (GI) examination, is an X-ray examination of the large intestine (colon and rectum). The test is used to help diagnose diseases and other problems that affect the large intestine. To make the intestine visible on an X-ray picture, the colon is filled with a contrast material containing barium. This is done by pouring the contrast material through a tube inserted into the anus. The barium blocks X-rays, causing the barium-filled colon to show up clearly on the X-ray picture.

Limitations:

Coverage Limitations for High Risk patients:

Individuals who are at high risk for colorectal cancer, payment may be made for a screening barium enema examination 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.

Coverage Limitations for patients who are not at risk:

Individuals age 50 or over who are not at high risk of colorectal cancer, payment may be made for a screening barium enema examination performed after at least 47 months have passed following the month in which the last screening barium enema or screening flexible sigmoidoscopy was performed.

Please note: Colorectal cancer screening; barium enema (G0122) should be used when a screening barium enema is performed NOT as an alternative to either a screening colonoscopy or a screening flexible sigmoidoscopy. This service will be denied as non-covered and the beneficiary is liable for payment.

Requirements:

The screening barium enema (single or double contrast) 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, or a screening colonoscopy, as appropriate, for the same individual.

Failed / Incomplete Colonoscopies:

1. Physicians should be reimbursed for the procedure that was actually performed, not for what was intended. A failed colonoscopy, e.g., the inability to extend beyond the splenic flexure, should be paid as a sigmoidoscopy (CPT 45330), as this, rather than a colonoscopy, is the procedure that was actually performed; therefore: List the CPT code G0105 (screening colonoscopy) or G0121 with the modifier 53 (discontinued procedure), to indicate a failed screening colonoscopy. The reimbursement is based on the allowed amount for a sigmoidoscopy.

2. In some instances, a provider may begin a screening colonoscopy, but, because of extenuating circumstances, be unable to complete the procedure. At another time, the provider may attempt and complete the intended screening colonoscopy on the patient. This situation parallels those of diagnostic colonoscopies in which the provider is unable to complete the colonoscopy because of extenuating circumstances and must attempt a complete colonoscopy at a later time. If coverage conditions are met, Medicare pays for both the uncompleted colonoscopy and the completed colonoscopy whether the colonoscopy is screening in nature or diagnostic.

3. When submitting a claim for the facility fee associated with this failed colonoscopy procedure in an Ambulatory Surgical Center (ASCs) use modifier 73- discontinued outpatient procedure prior to anesthesia administered or modifier 74- discontinued outpatient procedure after anesthesia administered as appropriate.

4. As with other services, modifier 22 should be used and extra payment allowed only when supporting documentation indicates that significantly more time and effort is involved than required in the typical sigmoidoscopy.

Deductible and Coinsurance:

There is no deductible and no coinsurance or co-payments for the fecal occult blood tests (CPT codes G0107 and G0328) and no deductibles applies to CPT codes G0104, G0105, G0106, G0120 and G0121 but coinsurance applies.

Reference: https://www.cms.gov/MLNMattersArticles/downloads/MM5387.pdf

To know more on the Reimbursement technique for Colonoscopies and Commercial insurances coverage details please visit http://codingahead.blogspot.com/2009/11/coding-for-colonoscpy-and-its.html

Bibliography:
https://www.cms.gov/ColorectalCancerScreening/

http://www.cms.gov/MLNMattersArticles/downloads/MM5127.pdf
https://www.highmarkmedicareservices.com/partb/reference/pdf/psc-b.pdf
http://www.aetna.com/provider/data/MedicarewZeroCopay.pdf
http://www.wpsmedicare.com/
http://www.ncbi.nlm.nih.gov/
http://www.aafp.org/afp/990115ap/313.html
http://www.webmd.com/



Popular Posts