Why Colorectal Cancer Screen is Conflicted

There is conflicting advice for colorectal cancer screening.

March was National Colorectal Cancer Awareness Month, intended to highlight the importance of screening for colorectal cancer. There are four types of screenings which include the following:

1. Fecal occult blood test (FOBT);
2. Colonoscopy;
3. Sigmoidoscopy; and
4. Barium enema (an alternative to screening sigmoidoscopy or screening colonoscopy).

Colorectal cancer is the third leading cancer resulting in death. But it doesn’t have to be, as it is considered highly preventable.

The most recent Coding Clinic on this topic was issued in the first quarter of 2019, when the question was about the diagnosis for a screening colonoscopy and abnormal Cologuard™ test. A cecal polyp was found and removed during the colonoscopy. The advice was to assign K63.5 (polyp of colon) as the first diagnosis due to the positive findings on the Cologuard™ test. This procedure would be considered diagnostic, and not a screening.

The screening diagnosis codes for malignancy are found in subcategory

Z12.1, with the fourth digits of:

         0 – Unspecified

         1 – Colon

         2 – Rectum

         3 – Small Intestine

The diagnosis codes for colorectal malignancy are found in categories C18, C19, C20, and C21, which are Hierarchical Condition Categories (HCCs).  The code for personal history of colon cancer is Z85.038. The diagnosis code for family history of colon cancer is Z80.0. 

The HCPCS codes for screening of colorectal cancer are:

Barium enema:             G0120 – alternative to screening colonoscopy

                                    G0106 – alternative to screening sigmoidoscopy

                                    G0122 – colorectal screening

Colonoscopy:               G0121 – not high risk

                                    G0105 – high risk

Sigmoidoscopy:           G0104 – flexible sigmoidoscopy

Blood-based biomark:  G0327

The Centers for Medicare & Medicaid Services (CMS) updated the National Coverage Determination for colorectal cancer screening, which was effective Jan. 1, 2023 and released Feb. 16, 2023. The advice is printed in MLN Matters (MM13017) and Change Request CR13017.

Transmittal R11865 updates this policy for the Medicare Coverage Manual 100-03, and is effective April 3, 2023. This transmittal reduces the age for colorectal cancer screening from 50 to 45. The document also changes the policy for the colonoscopy following an abnormal stool-based test (e.g., Cologuard™) being considered as diagnostic. According to this advice, the colonoscopy following the abnormal stool-based test would still be considered a screening. CPT® Assistant from January 2023, under the title “Medicare RBRVS Changes in 2023” also state this change.

Please be aware that this update is for coverage and not coding. Coding Clinic for the first quarter of 2023 does not address the change in the colorectal cancer screening policy.

Coders frequently are faced with coding to drop the bill versus coding correctly. Please have a discussion at your facility regarding how to manage this dilemma. Also, this policy is for Medicare coverage. Your research should include a review of your major payers to see if their medical policies have adopted this change in coverage.

Hopefully, Coding Clinic for the second quarter of 2023 will address this issue from a coding point of view. Please update your facility-specific coding guidelines with the results of your discussion. This information will be helpful in addressing any denials on the topic.

To add my personal spin to this story, last August I was diagnosed with moderate to severe ulcerative colitis, which is a risk factor for colorectal cancer. Due to my own fears, I had delayed my first screening colonoscopy until I had a problem. I had a great experience, and it was the best sleep that I had in months.

My ulcerative colitis is now in remission, and I am managing the disease with ENTYVIO, which is administered as a 30-minute infusion every eight weeks.

Do not delay your screening! Your life could depend upon it.

Programming note: Listen to Laurie Johnson’s live coding reports every Tuesday on Talk Ten Tuesdays at 10 Eastern with Chuck Buck and Dr. Erica Remer.