Pathology/Lab Coding Alert

With Medicare updates to coverage rules for colorectal cancer (CRC) screening two years in a row, you need to streamline your lab’s coding to make sure you’re getting all the pay you deserve.

Help is here: Use this rundown of screening CRC codes, plus an explanation of recent changes to make sure your lab is up to date.

Know the Covered CRC Screening Tests and Codes

For most screening CRC tests, Medicare requires you to use a HCPCS Level II code instead of a similar CPT^® code that you would use for essentially the same test performed for diagnostic purposes.

Under various circumstances, Medicare covers the following test codes for CRC screening:

• G0105 (Colorectal cancer screening; colonoscopy on individual at high risk)
• G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk)
• G0104 (Colorectal cancer screening; flexible sigmoid­oscopy)
• 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))
• G0328 (Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous)
• 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) Cologuard^®
• G0327 (Colorectal cancer screening; blood-based biomarker)
• G0106 (Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema)
• G0120 (Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema)
• G0122 (Colorectal cancer screening; barium enema)

Spotlight MPFS Changes

The Medicare Physician Fee Schedule (MPFS) final rule for both calendar year (CY) 2022 and 2023 included revisions to coverage for CRC screening.

2022: The MPFS for CY 2022 final rule resolved the long-standing problem of coverage for a screening colonoscopy or sigmoidoscopy that turns diagnostic because the surgeon removes suspicious tissue for pathologic diagnosis.

Specifically, the rule states, “When a planned colorectal cancer screening test, that is, screening flexible sigmoidoscopy or screening colonoscopy test, requires a related procedure, including removal of tissue or other matter, furnished in connection with, as a result of, and in the same clinical encounter as the screening test, it is considered to be a colorectal cancer screening test.”

Coding: In cases where screening turns diagnostic, pathologists may receive tissue exam requests from a screening colonoscopy that the surgeon reports with one of the following CPT^® codes rather than a G code:

• 45380 (Colonoscopy, flexible; with biopsy, single or multiple)
• 45384 (… with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps)
• 45385 (… with removal of tumor(s), polyp(s), or other lesion(s) by snare technique)
• 45331 (Sigmoidoscopy, flexible; with biopsy, single or multiple)
• 45333 (… removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps)

Additionally, you should see one of these codes in the surgical reports listed with modifier PT (Colorectal cancer screening test; converted to diagnostic test or other procedure) for Medicare payers, or 33 (Preventive Services) for non-Medicare payers to indicate that this is a screening test that turned diagnostic.

2023: The 2023 MPFS finalized CRC coverage changes to align with recent United States Preventative Services Task Force (USPSTF) and professional society recommendations.

Age: The Centers for Medicare & Medicaid Services (CMS) is reducing the minimum age for colorectal screenings from 50 to 45 years. Although most people are not eligible for Medicare at age 45, “Medicare usually sets the precedent, so this would enable any Advantage plan, or other federal plan, to follow along with Medicare’s policy. It also would put pressure on any commercial payer to uphold USPSTF measures,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

Complete screening: In addition to the age change, CMS is expanding the definition of CRC screening to include a “complete colorectal cancer screening.” This means Medicare will now cover (as a preventive service) a follow-up screening colonoscopy after a non-invasive stool-based test returns a positive result, eliminating the beneficiary’s out-of-pocket expense for both tests.

Diagnosis alert: As of now, ICD-10 has not formally instructed coders how to sequence diagnosis codes in situations when a positive fecal test leads to a colonoscopy. “For the time being, add the ICD-10 code R19.5 [Other fecal abnormalities] as the diagnosis below Z12.11 [Encounter for screening for malignant neoplasm of colon]. Also, code for the finding, such as K63.5 [Polyp of colon],” advises Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California. He also suggests watching how Medicare contractors and private payers process claims. “Patients should get no cost-sharing in this scenario,” he says.

Hold claims? Medicare contractor First Coast has announced that it will hold CRC screening test claims with dates of service on or after January 1, 2023 “until national editing related to age and frequency limitations is implemented per the updated policies finalized in the CY 2023 [MPFS].” (see medicare. fcso.com/Processing_Issues/0501553.asp). Check with your Medicare contractor to see if you can expect similar delays.

Understand how ‘Frequency’ and ‘Risk’ Influence Coverage

Medicare covers CRC screening for patients at high risk and non-high (average) risk of developing CRC, but coverage is different depending on the patient’s risk category.

Although Medicare’s list of risk factors may vary slightly for different screening methods, any one of the following items may put a patient in the high risk category, and absence of any conditions on the list places the patient in the average risk category:

• Personal history of CRC
• Personal history of adenomatous polyps
• Inflammatory bowel disease (including Crohn’s or ulcerative colitis)
• Positive CRC screening test result
• Family history of CRC or adenomatous polyp
• Family history of hereditary condition such as familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer

Once you understand the patient’s risk category, you can apply the appropriate coverage frequency rules.

High risk: For high risk patients at least 45 years of age:

• Medicare covers a screening colonoscopy (G0105 or G0120) once every 24 months;
• Medicare does not intend for other screening methods to replace colonoscopy for high-risk patients; and
• Medicare now covers an initial screening colonoscopy based on a positive non-invasive stool-based CRC screening test.

Average risk: With no high-risk factors or positive CRC screening test results, Medicare will cover screening CRC tests at the following frequency:

• Colonoscopy (G0121) – once every 120 months or 48 months following screening flexible sigmoidoscopy
• Flexible sigmoidoscopy (G0104 or G0106) – once every 48 months or 120 months after screening colonoscopy
• Barium enema (G0122) – once every 48 months
• Fecal occult blood test by peroxidase (82270) or immunoassay (G0328) method – once every 12 months
• Multi-target fecal DNA test such as Cologuard^® (81528) – once every 36 months
• Blood-based biomarker performed by lab certified under the Clinical Laboratory Improvement Amendments (CLIA) (G0327) – once every 36 months.