G0105 — Colorectal cancer screening; colonoscopy on individual at high risk
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
3.18
Facility
$164.67
Non-Facility
$378.10
Documentation Required
- Select the CPT code that accurately describes the diagnostic/therapeutic procedure that was performed or attempted during the colonoscopy.
- Append the -PT modifier to the selected CPT code to indicate a screening colonoscopy was converted to a diagnostic or therapeutic procedure.
- Use an appropriate ICD-10 diagnosis code indicating the procedure was a screening (example: Z80.0) when submitting the claim for a converted screening colonoscopy.
- Document clinical findings in the medical record that demonstrate the screening colonoscopy was converted to diagnostic/therapeutic (e.g., description of encountered pathology and performed intervention).
Key Coverage Criteria
- If a screening colonoscopy encounters pathology that necessitates intervention converting it to a diagnostic or therapeutic colonoscopy, bill using the appropriate diagnostic/therapeutic CPT code appended with the -PT modifier and an appropriate screening ICD-10 diagnosis.
- When beneficiaries are at high risk for colorectal malignancy, an ICD-10 screening code such as Z80.0 (family history of malignant neoplasm of digestive organs) may be used to indicate the procedure was a screening converted to diagnostic/therapeutic.
- A colonoscopy attempt that cannot be completed because of extenuating/unforeseen circumstances (e.g., inability to advance the colonoscope to the cecum or to a colon–small intestine anastomosis) is considered an incomplete/failed colonoscopy.
- Policy applies to both screening and diagnostic colonoscopies.
- Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered for surveillance of colonic neoplasia in patients with a history of colorectal cancer or colonic polyps.
- A follow-up procedure is covered 1 year after surgery for treatment of colorectal cancer when the patient is identified as high-risk for colon cancer and is eligible for continued screenings.
10 Active Policies
CIGNA-A004 — Preventive Care Services - (A004)
AETNA-CPB-0783 — In Vivo Analysis of Gastro-Intestinal and Urothelial Lesions
ANTHEM-CG-SURG-01 — CG-SURG-01 Colonoscopy
A55069 — Billing and Coding: Screening Colonoscopy Converted to a Diagnostic and/or Therapeutic Colonoscopy
A55227 — Billing and Coding: Incomplete Colonoscopy/Failed Colonoscopy
Related Codes
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