Primarily affecting men and women ages 50 and older, colorectal cancer is the third leading cause of cancer deaths in the United States. The risk of developing the disease increases with age.1 Patients with colorectal cancer rarely display any symptoms, and the cancer can progress unnoticed and untreated until it becomes fatal. The most common symptom of colorectal cancer is bleeding from the rectum. Other common symptoms include cramps, abdominal pain, intestinal obstruction, or a change in bowel habits.
Colorectal cancer is largely preventable through screening, which can find pre-cancerous polyps (growths in the colon) that can be removed before they develop into cancer. Screening can also detect cancer early when it is easier to treat and cure. Screenings are performed to diagnose or determine a beneficiary’s risk for
developing colorectal cancer. Colorectal cancer screening may consist of several different screening services to test for polyps or colorectal cancer. Each colorectal cancer screening can be used alone or in combination with each other.
Coverage Information
Medicare provides coverage of colorectal cancer screening for the early detection of colorectal cancer. All Medicare beneficiaries age 50 and older are covered; however, when an individual is at high risk, there is no minimum age required to receive a screening colonoscopy or a barium enema rendered as an alternative to a screening colonoscopy.
Medicare provides coverage for colorectal cancer screening as a Medicare Part B benefit. The beneficiary will pay nothing for the FOBT (there is no deductible and no coinsurance or copayment for this benefit). For all other procedures, the coinsurance or copayment applies; however, there is no deductible.
NOTE: Medicare does not waive the deductible if the colorectal cancer screening test becomes a diagnostic colorectal test; that is, the service actually results in a biopsy or removal of a lesion or growth.
If the flexible sigmoidoscopy or colonoscopy procedure is performed in a hospital outpatient department or in an ambulatory surgical center, the beneficiary will pay 25 percent of the Medicare-approved amount.
Coding and Diagnosis Information
G0104 Colorectal cancer screening; flexible sigmoidoscopy
G0105 Colorectal cancer screening; colonoscopy on individual at high risk
G0106 Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema
G0107* Colorectal cancer screening; fecal-occult blood test, 1-3
simultaneous determinations
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)
G0120 Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema
G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0122 Colorectal cancer screening; barium enema
G0328 Colorectal cancer screening; fecal occult blood test, immunoassay,
Diagnosis Requirements
V10.05 Personal history of malignant neoplasm of large intestine
V10.06 Personal history of malignant neoplasm of rectum, rectosigmoid junction,
and anus
555.0 Regional enteritis of small intestine
555.1 Regional enteritis of large intestine
555.2 Regional enteritis of small intestine with large intestine
555.9 Regional enteritis of unspecified site
556.0 Ulcerative (chronic) enterocolitis
556.1 Ulcerative (chronic) ileocolitis
556.2 Ulcerative (chronic) proctitis
556.3 Ulcerative (chronic) proctosigmoiditis
556.8 Other ulcerative colitis
556.9Ulcerative colitis, unspecified
Reasons for Claim Denial
The following are examples of situations where Medicare may deny coverage of colorectal cancer screening: `
* The beneficiary is under age 50.
* The beneficiary does not meet the criteria of being at high risk of developing colorectal cancer.
* The beneficiary has exceeded Medicare’s frequency parameters for coverage of colorectal cancer screening services.
