Coverage Policy Manual
Policy #: 2011045
Category: PPACA Preventive
Initiated: September 2010
Last Review: January 2019
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: COLORECTAL CANCER SCREENING

Description:
The Federal Patient Protection and Preventive Care Act was passed by Congress and signed into law by the President in March 2010.  The preventive services component of the law became effective 23 September 2010.  A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force.  
 
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
 
Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention.  Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds.  Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.  Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
 
Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, co-insurance, or co-pay).by Health Plans for appropriate preventive care services provided by an in-network provider.  If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, co-insurance, or copay may be applied.
 
Coding
In 2018, CPT released a new code 00812 specific for screening colonoscopy.
 
CPT 00812 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy
 
Prior to 2018, this service would have been reported with CPT 00810. CPT 00810 was deleted 12/31/2017.
 
If sedation is used for a screening colonoscopy, we would expect that CPT 00812 be used to report this service. Modifier -33 will not be required when reporting CPT 00812 because the service reported by CPT 00812 is inherently preventive.

Policy/
Coverage:
EFFECTIVE JANUARY 2019
 
Screening for colorectal cancer using fecal immunochemical test [FIT] (annually), CT colonography (every 5 years) sigmoidoscopy (every 10 years combined with annual FIT), or colonoscopy (every 10 years) is covered, beginning at age 50 years and continuing until age 75 years, for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-9 codes to report these screening services are V76.41 or V76.51.
 
The appropriate ICD-10 codes to report these screening services are Z12.11 or Z12.12.
 
Codes that may be used to report the procedures are G0104, G0105, G0121, G0328, 82270, or 82274.
 
HCPCS code G0500 should be billed for the first 15 minutes of sedation, if moderate (conscious) sedation is performed in conjunction with GI procedures (HCPCS G0104, G0105, G0121). If additional time is needed, CPT 99153 should be used for each additional 15 minutes.
 
CPT 00812 may also be billed in association with G0104, G0105 and G0121.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.
 
The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
It is possible that a screening study is converted to a diagnostic study or an intervention. When a screening study is converted to a diagnostic or interventional procedure no cost sharing will be applied. Codes that may be used to report these procedures include 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45346, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45388, 88305 and 00812. When these services are billed for a screening study converted to a diagnostic study or intervention they may be billed with Modifier ‘-33’ or Modifier ‘-PT’ – colorectal cancer screening test; converted to diagnostic test or other procedure.
 
Additionally, the related code CPT 88305 may be billed with this service and should be billed using Modifier ‘-33’. Modifier ‘-PT’ is not valid with this code.
 
EFFECTIVE PRIOR TO JANUARY 2019
 
Screening for colorectal cancer using fecal occult blood testing (annually), sigmoidoscopy (every 5 years combined with high-sensitivity fecal occult blood testing every 3 years), or colonoscopy (every 10 years) is covered, beginning at age 50 years and continuing until age 75 years, for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-9 codes to report these screening services are V76.41 or V76.51.
 
The appropriate ICD-10 codes to report these screening services are Z12.11 or Z12.12.
 
Codes that may be used to report the procedures are G0104, G0105, G0121, G0328, 82270, or 82274.
 
HCPCS code G0500 should be billed for the first 15 minutes of sedation, if moderate (conscious) sedation is performed in conjunction with GI procedures (HCPCS G0104, G0105, G0121). If additional time is needed, CPT 99153 should be used for each additional 15 minutes.
 
CPT 00812 may also be billed in association with G0104, G0105 and G0121.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.
 
The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
It is possible that a screening study is converted to a diagnostic study or an intervention. When a screening study is converted to a diagnostic or interventional procedure no cost sharing will be applied. Codes that may be used to report these procedures include 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45346, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45388, 88305 and 00812. When these services are billed for a screening study converted to a diagnostic study or intervention they may be billed with Modifier ‘-33’ or Modifier ‘-PT’ – colorectal cancer
screening test; converted to diagnostic test or other procedure.
 
Additionally, the related code CPT 88305 may be billed with this service and should be billed using Modifier ‘-33’. Modifier ‘-PT’ is not valid with this code.
 
EFFECTIVE SEPTEMBER 2017- DECEMBER 2017
 
Screening for colorectal cancer using fecal occult blood testing (annually), sigmoidoscopy (every 5 years combined with high-sensitivity fecal occult blood testing every 3 years), or colonoscopy (every 10 years) is covered, beginning at age 50 years and continuing until age 75 years, for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-9 codes to report these screening services are V76.41 or V76.51.
 
The appropriate ICD-10 codes to report these screening services are Z12.11 or Z11.12.
 
Codes that may be used to report the procedures are G0104, G0105, G0121, G0328, 82270, or 82274.
 
HCPCS code G0500 should be billed for the first 15 minutes of sedation, if moderate (conscious) sedation is performed in conjunction with GI procedures (HCPCS G0104, G0105, G0121). If additional time is needed, CPT 99153 should be used for each additional 15 minutes.
 
CPT 00810 may also be billed in association with G0104, G0105 and G0121.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.
 
The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
It is possible that a screening study is converted to a diagnostic study or an intervention. When a screening study is converted to a diagnostic or interventional procedure no cost sharing will be applied. Codes that may be used to report these procedures include G6022, G6024, 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45346, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45388, 88305 and 00810. When these services are billed for a screening study converted to a diagnostic study or intervention they may be billed with Modifier ‘-33’ or Modifier ‘-PT’ – colorectal cancer screening test; converted to diagnostic test or other procedure.
 
Additionally, the related code CPT 88305 may be billed with this service and should be billed using Modifier ‘-33’. Modifier ‘-PT’ is not valid with this code.
 
EFFECTIVE APRIL 2015 – AUGUST 2017
Screening for colorectal cancer using fecal occult blood testing (annually), sigmoidoscopy (every 5 years combined with high-sensitivity fecal occult blood testing every 3 years), or colonoscopy (every 10 years) is covered, beginning at age 50 years and continuing until age 75 years, for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-9 codes to report these screening services are V76.41 or V76.51.
 
The appropriate ICD-10 codes to report these screening services are Z12.11 or Z11.12.
 
Codes that may be used to report the procedures are G0104, G0105, G0121, G0328, 82270, or 82274. CPT 00810 may also be billed in association with G0104, G0105 and G0121. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.
 
The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
It is possible that a screening study is converted to a diagnostic study or an intervention. When a screening study is converted to a diagnostic or interventional procedure no cost sharing will be applied. Codes that may be used to report these procedures include G6022, G6024, 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45346, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45388, 88305 and 00810. When these services are billed for a screening study converted to a diagnostic study or intervention they may be billed with Modifier ‘-33’ or Modifier ‘-PT’ – colorectal cancer screening test; converted to diagnostic test or other procedure.
 
Additionally, the related code CPT 88305 may be billed with this service and should be billed using Modifier ‘-33’. Modifier ‘-PT’ is not valid with this code.
  
EFFECTIVE FEBRUARY 2015 – MARCH 2015
 
Screening for colorectal cancer using fecal occult blood testing (annually), sigmoidoscopy (every 5 years combined with high-sensitivity fecal occult blood testing every 3 years), or colonoscopy (every 10 years) is covered, beginning at age 50 years and continuing until age 75 years, for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-9 codes to report these services are V76.41 or V76.51.
 
Codes that may be used to report the procedures are G0104, G0105, G0121, G0328, 82270, or 82274. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.
 
The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
It is possible that a screening study is converted to a diagnostic study or an intervention. When a screening study is converted to a diagnostic or interventional procedure no cost sharing will be applied. Codes that may be used to report these procedures include G6022, G6024, 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45346, 45378, 45379, 45380, 45381, 45382, 45384, 45385 and/or 45388. These services should be billed with Modifier ‘-PT’ – colorectal cancer screening test; converted to diagnostic test or other procedure.
 
Other related codes are 00810 and 88305. Modifier PT is not valid with these two codes.
 
EFFECTIVE PRIOR TO FEBRUARY 2015
 
Screening for colorectal cancer using fecal occult blood testing (annually), sigmoidoscopy (every 5 years combined with high-sensitivity fecal occult blood testing every 3 years), or colonoscopy (every 10 years) is covered, beginning at age 50 years and continuing until age 75 years,  for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay).  
 
The appropriate ICD-9 codes to report these services are V76.41 or V76.51.
 
Codes that may be used to report the procedures are G0104, G0105, G0121, G0328, 82270, or 82274. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.  
 
The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
It is possible that a screening study is converted to a diagnostic study or an intervention. When a screening study is converted to a diagnostic or interventional procedure no cost sharing will be applied. Codes that may be used to report theses procedures include 45330, 45331, 45333, 45338, 45339, 45378, 45380, 45381, 45383, 45384, and/or 45385.  These services should be billed with Modifier ‘-PT’ – colorectal cancer screening test; converted to diagnostic test or other procedure.  Other related codes are 00810 and 88305.  Modifier PT is not valid with these two codes.  

Rationale:
Colorectal cancer is the third most common type of cancer and the second leading cause of cancer death in the United States.
 
These recommendations apply to adults 50 years of age and older, excluding those with specific inherited syndromes (the Lynch syndrome or familial adenomatous polyposis) and those with inflammatory bowel disease. The recommendations do apply to those with first-degree relatives who have had colorectal adenomas or cancer, although for those with first-degree relatives who developed cancer at a younger age or those with multiple affected first-degree relatives, an earlier start to screening may be reasonable. The recommendations are intended to apply to all ethnic and racial groups.
 
When the screening test results in the diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable.
 
Other USPSTF conclusions about other considerations of screening for colorectal cancer:
    • For adults age 76 to 85 years, there is moderate certainty that the net benefits of screening are small;
    • For adults older than age 85 years, there is moderate certainty that the benefits of screening do not outweigh the harms;
    • FIT-DNA with annual testing is not among the model-recommendable strategies because the efficiency ratio was larger than that of the benchmark colonoscopy strategy.
 

CPT/HCPCS:
00812Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy
45330Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
45331Sigmoidoscopy, flexible; with biopsy, single or multiple
45332Sigmoidoscopy, flexible; with removal of foreign body(s)
45333Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
45334Sigmoidoscopy, flexible; with control of bleeding, any method
45335Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance
45338Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45346Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)
45378Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
45379Colonoscopy, flexible; with removal of foreign body(s)
45380Colonoscopy, flexible; with biopsy, single or multiple
45381Colonoscopy, flexible; with directed submucosal injection(s), any substance
45382Colonoscopy, flexible; with control of bleeding, any method
45384Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
45385Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45388Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)
74263Computed tomographic (CT) colonography, screening, including image postprocessing
82270Blood, 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)
82274Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations
88305Level IV - Surgical pathology, gross and microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp, colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse Vagina, biopsy Vulva/labia, biopsy
99153Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)
G0104Colorectal cancer screening; flexible sigmoidoscopy
G0105Colorectal cancer screening; colonoscopy on individual at high risk
G0121Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0328Colorectal cancer screening; fecal occult blood test, immunoassay, 1-3 simultaneous determinations
G0500Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monit

References: PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act

Screening for Colorectal Cancer Topic page, October, 2008. U.S. Preventive Services Task Force; http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
CPT Codes Copyright © 2019 American Medical Association.