Does G0121 require prior authorization?

No, G0121 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for G0121?

Medicare facility rate: $165.00. Non-facility rate: $378.43. Work RVU: 3.18.

Verity

`G0121`, Colorectal cancer screening; colonoscopy on individual not meeting criteria for

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.
This document does not specify required documentation for coverage or billing (no explicit 'Documentation Requirements' section).

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.
Planned preventive screening colonoscopies performed in a hospital outpatient department are considered medically necessary for an individual who meets any of the following criteria: Advanced liver disease (MELD Score > 8) Anticipated need for transfusion Bleeding disorder requiring replacement factor or blood products or special infusion products to correct a coagulation defect Cardiac arrhythmia (symptomatic arrhythmia despite medication) Chronic obstructive pulmonary disease (COPD) (FEV1 < 50 [...]
Optical Biopsy System (SpectraScience): "an adjunct to lower gastrointestinal endoscopy for the evaluation of polyps less than 1 cm in diameter that the physician has not already elected to remove. The device is only to be used in deciding whether such polyps should be removed (which includes submission for histological examination)." (FDA PMA statement in text).
Narrow Band Imaging (NBI): differentiation of colorectal polyps (neoplastic vs non-neoplastic) and enhancement of adenoma detection during colonoscopy (multiple RCTs and systematic reviews evaluated NBI for adenoma detection and polyp characterization).
High-definition chromoendoscopy / dye chromoendoscopy: detection of flat and depressed neoplasms and increased polyp/adenoma detection compared with conventional colonoscopy (evaluated particularly for colorectal cancer screening and IBD surveillance).

10 Active Policies

PALMETTO-JJ-L34454, Colonoscopy /Sigmoidoscopy /Proctosigmoidoscopy

PALMETTO-JM-L34454, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

UHC-POL-screening-colonoscopy-procedures-site-service, Screening Colonoscopy Procedures – Site of Service

AETNA-CPB-0783, In Vivo Analysis of Gastro-Intestinal and Urothelial Lesions

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G0121, Colorectal cancer screening; colonoscopy on individual not meeting criteria for