Knowledge Base Article

Medicare covers a growing number of preventive services. Excellent resources to learn about Medicare’s Preventive services include a Medicare booklet and website for beneficiaries and a Preventive Services Chart and the Medicare manuals (Claims Processing Manual, Chapter 18, Benefit Policy Manual, Chapter 15, and NCD Manual, Chapter 1, Part 4) for providers. One such screening benefit is screening for colorectal cancer. Medicare covers fecal-occult blood testing, sigmoidoscopy, colonoscopy, barium enemas, and most recently Cologuard™ - A Multitarget Stool DNA Test for colorectal cancer screening. There are frequency and diagnosis limitations so read the coverage requirements carefully.

This year there is a new procedure code for Cologuard. See the update to MLN Matters Article MM9115. The previous HCPCS code, G0464, (Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (for example, KRAS, NDRG4 and BMP3)) expired effective December 31, 2015 and is replaced with CPT code 81528 for dates of service on and after January 1, 2016.

As a review, Medicare covers Cologuard sDNA testing:

• Effective for dates of service on and after October 9, 2014
• Once every three years for
• Asymptomatic Medicare patients
• Between the ages of 50-85 years
• At average risk of developing colorectal cancer
• For hospital outpatients (types of bill 13x, 14x, and 85x)
• With ICD-9 diagnosis codes V76.41 and V76.51 on the claim prior to October 1, 2015 and ICD-10 diagnosis codes Z12.12 and Z12.11 on the claim for October 1, 2015 and after
• With HCPCS code G0464 for October 9, 2014 through December 31, 2015 and for CPT code 81528 for January 1, 2016 and after
• There is no coinsurance or deductible for this test

Other coverage updates from last month are listed below. Notice that yet another Medicare Administrative Contractor (NGS) has published a new policy on urine drug testing.