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36.4.5 Cancer
36.4.5.1 Colorectal Cancer Screening
Screening colonoscopies and sigmoidoscopies are benefits of the Texas Medicaid Program. Screening refers to the testing of asymptomatic persons in order to assess their risk for the development of colorectal cancer. Screening has been shown to decrease mortality due to this cancer by detecting cancers at earlier stages and allowing the removal of adenomas, thus preventing the subsequent development of cancer.
The American Cancer Society and U.S. Preventive Services Task Force both recommend screening people at average risk for colorectal cancer beginning at age 50 by any of the following methods:
• A fecal occult blood test (FOBT)* or fecal immunochemical test (FIT) every year.
•Flexible sigmoidoscopy every 5 years.
•A FOBT* or FIT every year plus flexible sigmoidoscopy every 5 years, or (of these 3 options, the combination of FOBT or FIT every year plus flexible sigmoidoscopy every 5 years is preferable).
•Double-contrast barium enema every 5 years.
•Colonoscopy every 10 years.
*For FOBT, the take-home multiple sample method should be used.
The American Cancer Society and U.S. Preventative Task Force recommends screening for people at high-risk for colorectal cancer once very two years.
Indications/characteristics of a high-risk individual:
•A close relative (sibling, parent or child) has had colorectal cancer or an adenomatous polyp.
•There is a family history of familial adenomatous polyposis.
•There is a family history of hereditary non-polyposis colorectal cancer.
•There is a personal history of adenomatous polyps.
•There is a personal history of colorectal cancer.
•There is a personal history of colonic polyps.
•There is a personal history of inflammatory bowel disease, including Crohn's disease and ulcerative colitis.
Colorectal screening services are considered for reimbursement when submitted using procedure codes 2/F-G0104, 2/F-G0105, 4/I/T-G0106, 4/I/T-G0120, and 2-G0121 by associated risk category based on the American Cancer Society and U.S. Preventative Services Task Force frequency recommendations. Reimbursement for these procedure codes is considered when medical necessity is documented in the patient's record. Prior authorization is not required for this service.
Procedure code 4/I/T-G0122 is not a benefit of the Texas Medicaid Program.
Sigmoidoscopies
Procedure codes 2/F-G0104 and 4/I/T-G0106 are considered for reimbursement once every five years when submitted with diagnosis codes V1272 and V7651, as recommended by the American Cancer Society and the U.S. Preventive Services Task Force.
A screening barium enema may be substituted for a screening flexible sigmoidoscopy if the effectiveness has been established by the physician for substitution. Procedure code 4/I/T-G0106 may be used as an alternative to procedure code 2/F-G0104 respectively.
If during the course of screening flexible sigmoidoscopy, a lesion or growth is detected that results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a flexible sigmoidoscopy with biopsy or removal should reported rather than procedure code 2/F-G0104 or 4/I/T-G0106.
Colonoscopies: Average Risk
Procedure code 2-G0121 is considered for reimbursement once every ten years when submitted with diagnosis codes V1272 and V7651, as recommended by the American Cancer Society and U.S. Preventive Services Task Force for patients not meeting the criteria for high-risk.
If during the screening colonoscopy a lesion or growth is detected that results in a biopsy or removal of the growth, the procedure code for a colonoscopy with biopsy or removal of lesion should be reported rather than procedure code 2-G0121.
Colonoscopies: High-Risk
Procedure codes 2/F-G0105 and 4/I/T-G0120 are considered for reimbursement once every two years for patients meeting the definition of high-risk. Procedure codes 2/F-G0105 and 4/I/T-G0120 must be submitted with one of the following diagnosis codes:
A screening barium enema may be substituted for a screening colonoscopy if the effectiveness has been established by the physician for substitution. Procedure code 4/I/T-G0120 may be used as an alternative to procedure code 2/F-G0105 respectively.
If during the screening colonoscopy a lesion or growth is detected that results in a biopsy or removal of the growth, the procedure code for a colonoscopy with biopsy or removal of lesion should be reported rather than procedure code 2/F-G0105 or 4/I/T-G0120.
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