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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.15 Cancer Screening and Testing : 9.2.15.2 Colorectal Cancer Screening

9.2.15.2
Fecal occult blood tests, barium enemas, screening colonoscopies, and sigmoidoscopies are benefits of Texas Medicaid. 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 (ACS) and U.S. Preventive Services Task Force (USPSTF) both recommend screening people at average risk for colorectal cancer beginning at 50 years of age by any of the following methods:
A FOBT* or FIT every year plus flexible sigmoidoscopy every five years, or (of these three options, the combination of FOBT or FIT every year plus flexible sigmoidoscopy every five years is preferable)
*For FOBT, the take-home multiple sample method should be used.
The ACS and USPSTF recommends screening for people at high-risk for colorectal cancer once every two years.
Indications/characteristics of a high-risk individual:
Colorectal screening services are considered for reimbursement when submitted using procedure codes G0104, G0105, G0106, G0120, G0121, G0122, and G0328 by associated risk category based on the ACS and USPSTF frequency recommendations. Reimbursement for these procedure codes is considered when medical necessity is documented in the client’s record.
Fecal Occult Blood Tests
Procedure code G0328 may be reimbursed once per year for clients who are 50 years of age and older.
Barium Enemas
Procedure code G0122 is considered for reimbursement once every 5 years for clients who are 50 years of age and older.
Sigmoidoscopies
Procedure codes G0104 and G0106 are considered for reimbursement once every five years when submitted with diagnosis code Z0000, Z0001, Z1210, Z1211, Z1213, Z859, or Z86010, as recommended by the ACS and USPSTF. Diagnosis code Z0000 or Z0001 may be used for screening if no other diagnosis is appropriate for the service rendered, but not more frequently than recommended by the USPSTF.
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 G0106 may be used as an alternative to procedure code 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 must be reported rather than procedure code G0104 or G0106.
Colonoscopies: Average Risk
Procedure code G0121 is considered for reimbursement once every ten years when submitted with diagnosis code Z0000, Z0001, Z1210, Z1211, Z1213, or Z86010, as recommended by the ACS and USPSTF for clients who do not meet the criteria for high-risk. Diagnosis code Z0000 or Z0001 may be used for screening if no other diagnosis is appropriate for the service rendered, but not more frequently than recommended by the USPSTF.
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 G0121.
Colonoscopies: High-Risk
Procedure codes G0105 and G0120 are considered for reimbursement once every two years for clients who meet the definition of high-risk. Procedure codes G0105 and 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 G0120 may be used as an alternative to procedure code 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 G0105 or G0120.
9.2.15.2.1
Prior authorization is not required for colorectal screening.

Texas Medicaid & Healthcare Partnership
CPT only copyright 2014 American Medical Association. All rights reserved.