Screening Fecal-Occult Blood Tests (FOBT) (Codes G0107 & G0328)
Effective for services furnished on or after January 1, 2004, one screening FOBT (code G0107 or G0328) is covered for beneficiaries who have attained age 50, 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 done). Screening FOBT means: (1) a guaiac-based test for peroxidase activity in which the beneficiary completes it by taking samples from two different sites of three consecutive stools or, (2) a immunoassay (or immunochemical) test for antibody activity in which the beneficiary completes the test by taking the appropriate number of samples according to the specific manufacturer’s instructions. This expanded coverage is in accordance with revised regulations at 42 CFR 410.37(a)(2) that includes “ other tests determined by the Secretary through a national coverage determination.” This screening requires a written order from the beneficiary’s attending physician. (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.)
Screening Flexible Sigmoidoscopies (code G0104)
For claims with dates of service on or after January 1, 2002, carriers pay for screening flexible sigmoidoscopies (Code 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, nurse practitioner, or clinical nurse specialist (as defined in §1861(aa)(5) of the Act and in the Code of Federal Regulations at 42 CFR 410.74, 410.75, and 410.76) at the frequencies noted below. For claims with dates of service prior to January 1, 2002, pay for these services under the conditions noted only when they are performed by a doctor of medicine or osteopathy.
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 done).
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 §280.2.3) and the beneficiary has had a screening colonoscopy (code 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 (code G0121).
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 should be billed and paid rather than code G0104.
