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Effective March 1, 2021, Colorectal Cancer Screening Benefit Criteria to Change for Texas Medicaid

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.

Effective for dates of service on or after March 1, 2021, colorectal cancer screening benefit criteria will change for Texas Medicaid.

Fecal occult blood tests, multi-targeted stool deoxyribonucleic acid (mt-sDNA) tests, screening colonoscopies, and sigmoidoscopies are evidence-based methods of colorectal cancer screening.

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 mt-sDNA every 3 years
  • A flexible sigmoidoscopy every 5 years
  • A flexible sigmoidoscopy every 10 years in addition to annual FIT screening
  • A colonoscopy every 10 years

The U.S. Preventive Services Task Force (USPSTF) guidelines indicate that the net benefit of colorectal cancer screening in adults who are 76 years of age and older who have been previously screened is small. The risks should be considered on an individual basis, as screening in this age group is most appropriate for those healthy enough to undergo treatment.

The ACS and USPSTF recommends screening for people who are at high risk for colorectal cancer once every 2 years.

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

Fecal Occult Blood Tests

Procedure codes G0328 (with modifier QW) and 82270 may be reimbursed one service per rolling year for clients who are 45 years of age and older.

MT-sDNA Test

Procedure code 81528 may be reimbursed once every 3 years for clients who are 45 years of age and older for services rendered in the laboratory setting.


Procedure code G0104 may be reimbursed for clients who are 45 years of age and older.

Colonoscopies: Average Risk

Procedure code G0121 may be reimbursed once per 10 rolling years for clients who are 45 years of age and older.

Diagnosis code Z86010 will no longer be diagnosis-restricted for procedure code G0121 for average risk colonoscopies.


Barium enemas for colorectal cancer screening are not a benefit of Texas Medicaid.

For more information, call the TMHP Contact Center at 800-925-9126.