Becca, please refer to
https://gastro.org/practice-resources/reimbursement/coding/coding-faq-screening-colonoscopy/
For commercial and Medicaid patients who have a colonoscopy following a positive non-invasive CRC screening test, use modifier 33 with the appropriate colonoscopy code (e.g., 45378, 45380) based on the procedure(s) performed.
For Medicare beneficiaries who have a colonoscopy following a positive result for any of the following non-invasive stool-based CRC screening tests on or after 1/1/2023, use the appropriate HCPCS codes G0105 or G0121 with the KX modifier.
Screening guaiac-based fecal occult blood test (gFOBT) (CPT 82270)
- Screening immunoassay-based fecal occult blood test (iFOBT) (HCPCS G0328)
- Cologuard™ – multi-target stool DNA (sDNA) test (CPT 81528)
If modifier KX is not added to G0105 or G0121 for colonoscopy following a positive non-invasive stool-based test, Medicare will return the screening colonoscopy claim as “unprocessable.” If this happens, add modifier KX and resubmit the claim.
If polyps are removed during a screening colonoscopy for a Medicare patient, use the appropriate CPT code (45380, 45384, 45385, 45388) and add modifier PT (colorectal cancer screening test; converted to diagnostic test or other procedure) to each CPT code. However, it is important to note that if a polyp is removed during a screening colonoscopy, the Medicare beneficiary is responsible for 15% of the cost from 2023 to 2026. This falls to 10% of the cost from 2027 to 2029, and by 2030 it will be covered 100% by Medicare. Some Medicare beneficiaries are not aware that Medicare has not fully eliminated the coinsurance responsibility yet.
