Coding Guide – Free CRC Screening

Procedure codes

Commercial insurance:

• 45378 – Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

Medicare:

• G0121 – Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk, or
• G0105 – Colorectal cancer screening; colonoscopy on individual at high risk

ICD-10-CM codes

• Z12.11 – encounter for screening for malignant neoplasm of colon (Note: this code must be listed first when reporting multiple diagnosis codes)
• Z12.12 – encounter for screening for malignant neoplasm of rectum (Note: this code must be listed first when reporting multiple diagnosis codes)
• Z80.0 – family history of malignant neoplasm of digestive organs
• Z83.71 – family history of colonic polyps
• Z85.038 – personal history of other malignant neoplasm of large intestine
• Z85.048 – personal history of other malignant lesion of rectum, rectosigmoid junction and anus
• Z86.010 – personal history of colonic polyps

Insurance coverage

Commercial insurance:

• Colonoscopy, bowel prep, sedation, lab work and the hospital or ambulatory surgery center costs where the colonoscopy was performed are covered 100% by health insurance.

Medicare:

• Colonoscopy and sedation are covered 100% when no polyps are found.

View additional details & FAQs on coding for screening colonoscopies.

Procedure codes for commercial insurance and Medicare:

Select the appropriate code based on the type of removal performed. If multiple polyps/lesions were removed using different techniques, report each method separately. NOTE: You must add modifier 33 or PT (see below) to identify the polypectomy as a screening service and prevent the patient from being inappropriately billed.

• 45380 – Colonoscopy, flexible; with biopsy, single or multiple
• 45384 – Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
• 45385 – Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
• 45388 – Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)
  • Add modifier 33 (preventative services) to each CPT code for commercial insurance
  • Add modifier PT (colorectal cancer screening test; converted to diagnostic test or other procedure) to each CPT code for Medicare

ICD-10-CM codes

• Z12.11 – encounter for screening for malignant neoplasm of the colon (Note: this code must be listed first when reporting multiple diagnosis codes)
• Z12.12 – encounter for screening for malignant neoplasm of rectum (Note: this code must be listed first when reporting multiple diagnosis codes)
• D12.0 – benign neoplasm of the cecum
• D12.4 – benign neoplasm of the descending colon
• D12.8 – benign neoplasm of the rectum

Insurance coverage

Commercial insurance:

• Colonoscopy, bowel prep, sedation, lab work and the hospital or ambulatory surgery center costs where the colonoscopy with polypectomy was performed are covered 100% by health insurance.

Medicare:

• In 2022, if a polyp is removed the patient is responsible for 20% of the cost. From 2023 to 2026, patient responsibility is 15% of the cost, from 2027 to 2029 it falls to 10% and by 2030 it will be covered 100% by Medicare.

View additional details & FAQs on coding for screening colonoscopies. 

Procedure codes:

Select the appropriate code based on the type of test performed.

NOTE: You must add modifier 33 or KX (see below) to prevent the patient from being inappropriately billed for the colonoscopy following a positive non-invasive test.

Commercial insurance:

• FIT: 82274 – Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations
• FOBT: 82270 – Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection)
• Multi-target stool DNA test: 81528 – Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result

Medicare:

• FIT: G0328 – Colorectal Cancer Screening; Immunoassay, Fecal-Occult Blood Test, 1-3 Simultaneous Determinations
• FOBT: 82270 – Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided 3 cards or single triple card for consecutive collection)
• Multi-target stool DNA test: 81528 – Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers (KRAS mutations, promoter methylation of NDRG4 and BMP3) and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result
• Modifiers:
  • Add modifier 33 (preventative services) to each CPT code for commercial insurance
  • Add modifier KX (Requirements specified in the medical policy have been met) to the screening colonoscopy HCPCS code for Medicare

ICD-10-CM codes

• Z12.10 – encounter for screening for malignant neoplasm of intestinal tract, unspecified
• Z12.11 – encounter for screening for malignant neoplasm of colon
• Z12.12 – encounter for screening for malignant neoplasm of rectum

Insurance coverage

Commercial insurance:

• Pays for both the stool-based test and colonoscopy (including polyp removal) after a positive stool test if it was done after May 31, 2022. For tests performed before May 31, 2022, the stool-based test is covered at 100%, but patients might have to pay some of the costs for the colonoscopy.

Medicare:

• Pays for both the stool-based test and screening colonoscopy at no cost as of Jan. 1 2023, but patients may have to pay some of the cost of the colonoscopy if tpolyps are removed.

For a colonoscopy following a positive stool-based test

• Make sure you used the correct modifier.
  • Use modifier 33 with the appropriate colonoscopy code for patients with commercial insurance.
  • Use modifier KX with the appropriate HCPCS code (G0105, G0121) if polyps are not removed for patients with Medicare. If polyps are removed, Medicare considers the colonoscopy to be “diagnostic” and coinsurance will apply.
• Ask your patient if their plan was created on or before March 23, 2010, or if they have an employer-sponsored health care plan. These plans are not required to provide all the benefits and protections of the Affordable Care Act and are not required to cover colonoscopy following a positive stool-based test.
• Contact the insurance company and ask why the colonoscopy claim was denied.
• Inform the claims representative of guidance from the U.S. Department of Labor (DOL) that health plans and insurers “must cover and may not impose cost sharing with respect to a colonoscopy conducted after a positive non-invasive stool-based screening test” for plan or policy years beginning on or after May 31, 2022. See questions 6 (page 9) and 7 (page 12) of the DOL FAQ About Affordable Care Act Implementation. 

For a screening colonoscopy when a polyp was removed

• Make sure you used the correct modifier. Use modifier 33 with the appropriate colonoscopy code for patients with commercial insurance.
• Ask your patient if their plan was created on or before March 23, 2010, or if they have an employer-sponsored health care plan. These plans are not required to provide all the benefits and protections of the Affordable Care Act and are not required to cover colonoscopy following a positive stool-based test.
• Contact the insurance company and ask why the colonoscopy claim was denied.
• Inform the claims representative of guidance from the U.S. Department of Health and Human Services (HHS) that “the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure.” See question 5 of the HHS Affordable Care Act Implementation FAQs.