G0121 — Colorectal cancer screening; colonoscopy on individual not meeting criteria for 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
$165.00
Non-Facility
$378.43
Documentation Required
- Medical record must document the extenuating/unforeseen circumstances and the specific inability to advance the colonoscope to the cecum or colon–small intestine anastomosis to support billing as an incomplete procedure.
- Submit the failed colonoscopy on the claim using CPT 45378, HCPCS G0105 or G0121, or CPT 44388 (stoma) with modifier -53 appended.
- If a covered colonoscopy is later attempted and completed, submit the completed procedure claim; Medicare will pay for the completed colonoscopy according to its standard payment methodology provided all coverage conditions are met.
- When performing endoscopy for indications that are generally not covered, submit additional documentation evidencing the medical necessity of the procedure for review.
Key Coverage Criteria
- 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 to evaluate an abnormality on barium enema or other imaging likely to be clinically significant (e.g., filling defect, stricture, inadequate exam).
- Evaluation of unexplained gastrointestinal bleeding including hematochezia not thought to be from a rectal/perianal source, melena of unknown origin, or presence of fecal occult blood.
- Evaluation of unexplained iron deficiency anemia.
- Surveillance examination of the entire colon to evaluate for synchronous colonic cancer or polyps in a patient with treatable cancer or polyps.
8 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
A55227 — Billing and Coding: Incomplete Colonoscopy/Failed Colonoscopy
L34454 — Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy
Related Codes
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