Page 268 - Medicare Benefit Policy Manual

The following noncovered HCPCS codes are used to allow claims to be billed and denied
for beneficiaries who need a Medicare denial for other insurance purposes for the dates of
service indicated:

A. From January 1, 1998 Through June 30, 2001, Inclusive

Code G0121 (colorectal cancer screening; colonoscopy on an individual not meeting
criteria for high risk) should be used when this procedure is performed on a beneficiary
who does NOT meet the criteria for high risk. This service should be denied as
noncovered because it fails to meet the requirements of the benefit for these dates of
service. The beneficiary is liable for payment. Note that this code is a covered service for
dates of service on or after July 1, 2001.

B. On or After January 1, 1998

Code G0122 (colorectal cancer screening; barium enema) should be used when a
screening barium enema is performed NOT as an alternative to either a screening
colonoscopy (code G0105) or a screening flexible sigmoidoscopy (code G0104). This
service should be denied as noncovered because it fails to meet the requirements of the
benefit. The beneficiary is liable for payment.

280.3 - Screening Mammography
(Rev. 1, 10-01-03)
A3-3660.10, B3-4601.1

Section 4163 of the Omnibus Budget Reconciliation Act of 1990 added §1834(c) of the
Act to provide for Part B coverage of mammography screening performed on or after
January 1, 1991. The term “screening mammography” means a radiologic procedure
provided to an asymptomatic woman for the purpose of early detection of breast cancer
and includes a physician’s interpretation of the results of the procedure. Unlike
diagnostic mammographies, there do not need to be signs, symptoms, or history of breast
disease in order for the exam to be covered.

A doctor’s prescription or referral is not necessary for the procedure to be covered.
Payment may be made for a screening mammography furnished to a woman at her direct
request, and based on a woman’s age and statutory frequency parameter.

Section 4101 of the Balanced Budget Act (BBA) of 1997 provides for annual screening
mammographies for women over 39 and waives the Part B deductible. Coverage applies
as follows:

Age Screening Period

Less than 35 No payment may be made for a screening mammography performed on
years old a woman under 35 years of age.