Coding Guide – Free CRC Screening

Here are the most common colorectal cancer (CRC) screening tests — including colonoscopies and stool-based tests — with guidance on how to code for them and what patients can usually expect to pay.

You can also view additional details & FAQs on coding for screening colonoscopies. 

Doctor typing at computer

Ensure that you and your patients get reimbursed for eligible CRC screening procedures

New policies are making colorectal cancer (CRC) screenings free to more people and eliminating surprise bills, but only if doctors and facilities submit the correct procedure and diagnosis codes. This guide will identify the correct codes and show you how to help patients who get an unexpected bill after undergoing a colorectal cancer screening.

Here are the most common CRC screening tests, how to code for them, and what patients with commercial insurance and Original Medicare can usually expect to pay depending on whether they have commercial insurance or Medicare. (Note: Rules for Medicaid vary by state. Commercial plans in place on or before March 23, 2010, and employer-sponsored health care plan are not required to follow the rules below.)

Procedure codes

Commercial insurance
45378Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
Medicare
G0121Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk, or
G0105Colorectal cancer screening; colonoscopy on individual at high risk

 

ICD-10-CM codes

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

 

Insurance coverage

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

45380Colonoscopy, flexible; with biopsy, single or multiple
45384Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
45385Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45388Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre- and post-dilation and guide wire passage, when performed)
Modifiers– 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

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

 

Insurance coverage

Commercial insuranceColonoscopy, 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.
MedicareIn 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.

Commercial insurance
FIT: 82274Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations
FOBT: 82270Blood, 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: 81528Oncology (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: G0328Colorectal Cancer Screening; Immunoassay, Fecal-Occult Blood Test, 1-3 Simultaneous Determinations
FOBT: G0107Colorectal Cancer Screening; Fecal-Occult Blood Test, 1-3 Simultaneous Determinations
Multi-target stool DNA test: G0464Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3)

 

ICD-10-CM codes

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

 

Insurance coverage

Commercial insurancePays 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.
MedicarePays for the stool-based test at no cost, but patients may have to pay some of the cost of the colonoscopy if they have a positive test result.

For a colonoscopy following a positive stool-based test

  • 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

  • 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

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.

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: G0107 – Colorectal Cancer Screening; Fecal-Occult Blood Test, 1-3 Simultaneous Determinations
  • Multi-target stool DNA test: G0464 – Colorectal cancer screening; stool-based DNA and fecal occult hemoglobin (e.g., KRAS, NDRG4 and BMP3)

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 the stool-based test at no cost, but patients may have to pay some of the cost of the colonoscopy if they have a positive test result.

For a colonoscopy following a positive stool-based test

  • 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

  • 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