Revenue Cycle Insider

Question: I’ve heard there are recent changes to Medicare coverage for colorectal cancer (CRC) screenings. Could you please explain what is different, and describe correct coding for these procedures?

Ohio Subscriber

Answer: The 2025 Medicare Physician Fee Schedule (MPFS) final rule includes some revisions to coverage for CRC screenings. The changes will go into effect on Jan. 1, 2025.

The Centers for Medicare & Medicaid Services (CMS) finalized the following three policy updates for CRC screenings:

• Halt coverage for barium enema as a CRC screening tool.
• Add coverage for computed tomography colonography (CTC) as a CRC screening tool, which physicians may perform once every five years for patients at least 45 years of age.
• Expand coverage for “complete colorectal cancer screening” to include follow-up screening colonoscopy after a positive Medicare-covered blood-based CRC biomarker screening test. Medicare previously considered only stool-based CRC biomarker screening to warrant covered, follow-up screening colonoscopy.

The final rule also clarifies that a follow-up screening colonoscopy is not subject to screening colonoscopy frequency limitations when performed as part of a complete colorectal cancer screening following an abnormal noninvasive screening test result.

Drill down to the codes: Medicare covers the following codes once every 24 months for patients at high risk for CRC:

• G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) or
• G0120 (Colorectal cancer screening; alternative to G0105, screening colonoscopy, barium enema) (Note: watch for possible changes to this code to remove “barium enema” and include CTC.)

For patients at low CRC risk, Medicare covers the following codes once every 10 years after colonoscopy or every four years after flexible sigmoidoscopy:

• G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk)
• G0104 (Colorectal cancer screening; flexible sigmoidoscopy)
• G0106 (Colorectal cancer screening; alternative to G0104, screening sigmoidoscopy, barium enema) (Also watch for a potential change to this code descriptor.)

Consider one of the following codes for initial noninvasive lab-test screening. If findings are positive, these are part of a “complete colorectal cancer screening,” which would involve a covered, follow-up screening colonoscopy:

• 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). Medicare covers this test, known as a fecal occult blood test (FOBT), once every 12 months.
• G0328 (Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous), Medicare covers this test, known as a fecal immunoassay test (FIT), once every 12 months.
• 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). Medicare covers this test, known as Cologuard, once every 36 months.
• G0327 (Colorectal cancer screening; blood-based biomarker). Per National Coverage Determination (NCD) 210.3, Medicare covers these Food and Drug Administration-(FDA-) approved, blood-based CRC biomarker tests, such as Guardant Health’s “Shield,” every 36 months.

Note that CMS did not add coverage for the multi-target mRNA stool test called Colosense, which was FDA approved earlier this year.

Ellen Garver, BS, BA, Contributing Writer