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Effective March 1, 2021, Colorectal Cancer Screening Benefit Criteria to Change for CSHCN Services Program

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Effective for dates of service on or after March 1, 2021, benefit criteria will change for colorectal cancer screening for the Children with Special Health Care Needs (CSHCN) Services Program.

The American Cancer Society (ACS) recommends screening people at average risk for colorectal cancer beginning at 45 years of age by any of the following methods:

  • A fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year.
  • A multi-targeted stool deoxyribonucleic acid (mt-sDNA) every 3 years.
  • A flexible sigmoidoscopy every 5 years.
  • A FIT every year plus a flexible sigmoidoscopy every 10 years.
  • A colonoscopy every 10 years.

Note: For FOBT, the take-home multiple sample method with three samples should be used.

A personal history of inflammatory bowel disease, including Crohn’s disease and ulcerative colitis, will be added to the list of indications or characteristics of a high-risk individual.

Procedure codes G0106, G0120, and G0122 will no longer be reimbursed for colorectal cancer screenings.

Reimbursement

Procedure code 81528 may be reimbursed once every 3 years for clients who are 45 years of age or older.

Procedure codes 82270 and G0328 may be reimbursed for clients who are 45 years of age or older.

Procedure code G0104 may be reimbursed once every 5 years, or as recognized by the ACS or the U.S. Preventive Services Task Force (USPSTF), for clients who are 45 years of age or older to ambulatory surgical centers (freestanding and hospital-based) for services rendered in the hospital setting.

Procedure code G0121 may be reimbursed once every 10 rolling years.

Exclusions

Barium enemas for colorectal cancer screening are not a benefit of the CSHCN Services Program.

For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.