EST. 1999
Colorectal Cancer Screening
Service:
USPSTF: United States Preventative Services Task Force
USPSTF:B The USPSTF recommends screening for colorectal cancer in adults ages 45 to 49 years.
USPSTF:A
The USPSTF recommends screening for colorectal cancer in all adults aged 50 to 75 years.
Also refer to the Medical Policies titled Outpatient Surgical Procedures – Site of Service;
Screening Colonoscopy Procedures – Site of Service; and
Magnetic Resonance Imaging (MRI) and
Computed Tomography (CT) Scan – Site of Service
Colonscopy
Procedure Code(s):
Preventative Colonoscopy:
G0105, G0121
Preventative Colonoscopy when billed with Certain Codes (see Preventative Benefit Instructions):
44388*, 44389*, 44392*, 44394*, 45378*, 45380*, 45381*, 45384*, 45385*, 45388*
Diagnosis Code(s):
Applies to Procedure Codes with asterisk (*) above:
Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z80.0, Z83.710, Z83.711, Z83.718, Z83.719, 783.72, Z83.79
NOTE: Also see the Colonoscopy Pre-Op Consultation below.
Preventive Benefit Instructions:
Age Limits: 45-75 years (ends on 76th birthday.)
Codes G0105 and G0121 do not have diagnosis code requirements for preventative benefits to apply.
Codes with an asterisk (*) are preventative when:
Billed with one of the diagnosis codes listed (Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z80.0, Z83.710, Z83.711, Z83.718, Z83.719, 783.72, Z83.79);
Billed in addition to G0104, G0105, G0121, G0328 or S0285
Sigmoidoscopy
Procedure Code(s):
Preventative Sigmoidoscopy:
G0104
Preventative Sigmoidoscopy when billed with Certain Codes (see Preventative Benefit Instructions):
45330*, 45331*, 44333*, 45388*, 45346*
Diagnosis Code(s):
Applied to Procedure Codes with asterisk (*) above:
Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z80.0, Z83.710, Z83.711, Z83.718, Z83.719, Z83.72, Z83.79
Preventative Benefit Instructions:
Age Limits: 45-75 years (ends on 76th birthday).
Code G0104 does not have diagnosis code requirements for preventive benefits to apply.
Codes with an asterisk (*) are preventive when:
Billed with one of the diagnosis codes listed (Z00.00, Z00.01, Z12.10, Z12.11, Z12.12. Z80.0, Z83.710, Z83.711, Z83.718, Z83.719, Z83.72, Z83.79) or
Billed in addition to codes G0104, G0105, G0121, G0328 or S0285
Pathology and Anesthesia (for Colonoscopy or Sigmoidoscopy)
Procedure Code(s):
Pathology:88304, 88305
Anesthesia:00811, 00812, 99152, 99153, 99156, 99157, G0500
Diagnosis Code(s):
Applies to the Pathology and Anesthesia codes listed above:
Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z80.0, Z83.710, Z83.711, Z83.718, Z83.719, Z83.72, Z73.79
Preventive Benefit Instructions:
Age Limits: 45-75 years (ends on 76th birthday).
Requires both of the following:
One of the diagnosis codes listed (Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z80.0, Z83.710, Z83.711, Z83.718, Z83.719, Z83.72, Z73.79); and
One of the procedure codes listed in the Colonoscopy row or the Sigmoidoscopy row.
Note: Preventive benefits apply when the surgeon's claim is preventive.
Fecal Occult Blood Testing (FOBT) and Fecal Immunochemical Test (FIT)
Procedure Code(s):
Preventative:
G0238
Preventive When Billed with Certain Codes (See Preventative Benefit Instructions):
82270*, 82274*
Diagnosis Code(s):
Applies to Procedure Codes with asterisk (*) above:
Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z80.0, Z83.710, Z83.711, Z83.718, Z83.719, Z83.72, Z83.79
Preventive Benefit Instructions:
Age Limits: 45-75 years (ends on 76th birthday).
Code G0328 does not have diagnosis requirements for preventive benefits to apply.
Codes with an asterisk (*) are preventative when:
Billed with one of the diagnosis codes listed (Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z80.0, Z83.710, Z83.711, Z83.718, Z83.719, Z83.72, Z73.79); or
Billed in addition to G0104, G0105, G021, G0328 or S0285.
Fecal DNA
Procedure Code(s):
0464U, 81528
Diagnosis Code(s):
Code 81528 does not have diagnosis code requirements for preventative benefits to apply.
Preventive Benefit Instructions:
Age Limits: 45-75 years (ends on 76thbirthday).
Benefit is limited to once every 3 years
Codes 0464U and 81528 do not have diagnosis code requirements for preventive benefits to apply.
Pre-Op Consultation:
Procedure Code(s):
S0285
Preventive when billed with one of the diagnosis codes listed below:
99202*, 99203*, 99204*, 99205*, 99211*, 99212*, 99213*, 99214*, 99215*, 99242*, 99243*, 99244*, 99245*, 99417*
Diagnosis Code(s):
Applied to Procedure Codes with asterisk (*) above:
Z12.10, Z12.11, Z12.12, Z80.0, Z83.710, Z83.711, Z83.718, Z83.719, Z83.72, Z73.79
Note: For additional information on the reimbursement of consultation codes 99242-99245 refer to the reimbursement policy titled Consultation Services.
Preventive Benefit Instructions:
Age Limits: 45-75 years (ends on 76th birthday).
Code S0285 does not have diagnosis code requirements for preventive benefits to apply.
Codes with an asterisk (*) are preventive when billed with one diagnosis codes listed
(Z00.00, Z00.01, Z12.10, Z12.11, Z12.12, Z80.0, Z83.710, Z83.711, Z83.718, Z83.719, Z83.72, Z73.79)
Computed Tomographic Colonography (Virtual Colonoscopy):
Procedure Code(s):
74263
Diagnosis Code(s):
Does not have diagnosis code requirements for preventative benefit to apply.
Preventative Benefit Instructions:
Age Limits: 45-75 years (ends on 76th birthday).
Does not have diagnosis code requirements for preventive benefit to apply.
Prior authorization requirements may apply, depending on plan.