Page 262 - Medicare Benefit Policy Manual

the Criteria for Being at High-Risk for Developing Colorectal
Cancer (Code G0121)

Effective for services furnished on or after July 1, 2001, screening
colonoscopies (code G0121) are covered when performed under the
following conditions:

1. On individuals not meeting the criteria for being at high
risk for developing colorectal cancer (refer to §280.2.3);

2. At a frequency of once every 10 years (i.e., at least 119 months
have passed following the month in which the last covered
G0121 screening colonoscopy was performed); and

3. If the individual would otherwise qualify to have covered a
G0121 screening colonoscopy based on the above (see
§§280.2.2.D.1 and 2) but has had a covered screening flexible
sigmoidoscopy (code G0104), then the individual may have a
covered G0121 screening colonoscopy only after at least 47
months have passed following the month in which the last
covered G0104 flexible sigmoidoscopy was performed.

NOTE: I f during the course of the screening colonoscopy, a lesion or
growth is detected which results in a biopsy or removal of the growth,
the appropriate diagnostic procedure classified as a colonoscopy with
biopsy or removal should be billed and paid rather than code G0121.

Effective January 1, 2023, colorectal cancer screening tests include a follow-on
Screening Colonoscopy Performed on Individuals Not Meeting the Criteria for Being
at High-Risk for Developing Colorectal Cancer after a Medicare covered non-
invasive stool-based colorectal cancer screening test returns a positive result. Non-
invasive stool-based colorectal cancer screening tests include:

• Screening Guaiac-based Fecal Occult Blood Test (gFOBT) (82270)
• Screening Immunoassay-based Fecal Occult Blood Test (iFOBT) (G0328)
• Screening The Cologuard™ – Multi-target Stool DNA (sDNA) Test (81528)

The frequency limitations described for Colonoscopies Performed on Individuals Not
Meeting the Criteria for Being at High-Risk for Developing Colorectal Cancer in this
section shall not apply in the instance of a follow-on Screening Colonoscopy
Performed on Individuals Not Meeting the Criteria for Being at High-Risk for
Developing Colorectal Cancer after a Medicare covered non-invasive stool-based
colorectal cancer screening test returns a positive result. For complete claims
processing information, refer to Pub 100-04, Medicare Claims Processing Manual,
chapter 18, section 60.