Thursday, January 30, 2020

CPT G0121, G0122, G0328, G0464

Procedure code and description

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 (noncovered). 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)


Medicare billing Guidelines

For colorectal cancer screening using multitarget sDNA test, Medicare covers the beneficiaries who fall into ALL of the following three categories:

• Aged 50 to 85 years
• Asymptomatic
• At average risk of developing colorectal cancer

For screening colonoscopies, fecal occult blood tests (FOBTs), flexible sigmoidoscopies, and barium enemas, Medicare covers all the beneficiaries who are:
• 50 years and older and at normal risk of developing colorectal cancer, AND/OR
• At high risk of developing colorectal cancer
There is no age limitation for coverage of screening colonoscopies.


Codes G0105 and G0121 (colorectal cancer screening colonoscopies) must be paid at rates consistent with payment for similar or related services under the physician fee schedule, not to exceed the rates for a diagnostic colonoscopy (CPT code 45378). (The same RVUs have been assigned to codes G0105 and G0121 as those assigned to CPT code 45378.) 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 procedure classified as a colonoscopy with biopsy or removal must be billed and paid rather than code G0105 or G0121.


Screening colonoscopy

AHA Coding Clinic provides guidance in assigning the principal or first-listed diagnosis code when the physician documents that the colonoscopy is performed for screening purposes only. Code V76.51 is used first and any findings such as polyps, diverticulosis, or hemorrhoids are listed second; see Coding Clinic, First Quarter 1999 Page: 4. CPT codes are reported based on the procedure documented, and whether the patient is Medicare. If the patient is not Medicare, the appropriate CPT, (HCPCS Level I) code is assigned. If the patient is Medicare and no other procedures, such as a polypectomy or biopsy are performed, then either code G0105 or G0121,
(HCPCSL Level II) codes are assigned. G0105 is assigned if the patient qualifies as high risk using the following criteria:

* A personal history of colorectal cancer or
* A family history of familial adenomatous polyposis or
* A family history of hereditary nonpolyposis colorectal cancer or
* A personal history of adenomatous polyps or
* Inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis or
* A close relative (sibling, parent, or child) has had colorectal cancer or an adenomatous polyp.

HCPCS code G0121 is assigned if the patient does not qualify as high risk.


Denial codes


A. If a claim for a screening fecal-occult blood test, a screening flexible sigmoidoscopy, or a barium enema is being denied because of the age of the beneficiary, use the following MSN or EOMB message:

“This service is not covered for beneficiaries under 50 years of age.” (MSN Message 18-13, EOMB Message 18-22)

B. If the claim for a screening fecal-occult blood test, a screening colonoscopy, a screening flexible sigmoidoscopy, or a barium enema is being denied because the time period between the same test or procedure has not passed, use the following MSN or EOMB message: “Service is being denied because it has not been (12, 24, 48, 120) months since your last (test/procedure) of this kind.” (MSN Message 18-14, EOMB Message 18-23)

C. If the claim is being denied for a screening colonoscopy or a barium enema because the beneficiary is not at a high risk, use the following MSN or EOMB message: “Medicare only covers this procedure for beneficiaries considered to be at a high risk for colorectal cancer.” (MSN Message 18-15, EOMB Message 18-24)

D. If the claim is being denied because payment has already been made for a screening flexible sigmoidoscopy (code G0104), screening colonoscopy (code G0105), or a screening barium enema (codes G0106 or G0120), use the following MSN or EOMB message:

“This service is denied because payment has already been made for a similar procedure within a set timeframe.” (MSN Message 18-16, EOMB Message 18-25)

NOTE: The above messages (MSN 18-16 and EOMB 18-25) should only be used when a certain screening procedure is performed as an alternative to another screening procedure. For example: If the claims history indicates a payment has been made for code G0120 and an incoming claim is submitted for code G0105 within 24 months, the incoming claim should be denied.



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