What ICD-10/diagnosis code(s) should be used for Cologuard? To process claims for Medicare/Medicare Advantage patients, claims must include either ICD-10 diagnosis code Z12. 11 (encounter for screening for malignant neoplasm of colon) or Z12. 12 (encounter for screening for malignant neoplasm of rectum).
What is the ICD 10 code for positive ColoGuard test?
ICD-10 codes covered if selection criteria are met: C18.0 - C21.8: Malignant neoplasm of colon, rectosigmoid junction, rectum, anus and anal canal: C7a.020 - C7a.026: Malignant carcinoid tumors of the appendix, large intestine, and rectum: D12.0 - D12.9: Benign neoplasm of colon, rectum, anus and anal canal: D3a.020 - D3a.029
What percentage of positive Cologuard tests are cancer?
What percentage of positive cologuard tests are cancer? How Accurate is the Cologuard test? Cologuard can detect 92% of cancers but only 42% of large precancerous polyps. Cologuard is better at detecting cancer than FIT (92% vs 70% for FIT), but the false positive rate is higher.Cologuard has a 12% false positive rate, and that rate increases as people age.
What does a positive ColoGuard test mean?
What does a positive mean on a cologuard test? A positive result does not necessarily mean that you have cancer. It means that Cologuard detected DNA and/or hemoglobin biomarkers in the stool which are associated with colon cancer or precancer.
Does UHC cover Cologuard?
UnitedHealthcare’s decision follows Aetna’s March ruling to cover the DNA test once every 3 years. It is also covered by Humana, Cigna, and Tricare. Colorectal cancer (CRC) is the third most common cancer in the United States.
What is the ICD-10 code for colon screening?
ICD-10 code Z12. 11 for Encounter for screening for malignant neoplasm of colon is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
Is cologuard considered a screening?
Cologuard and a colonoscopy can be used together to screen for colon cancer. Cologuard works as a noninvasive, first-line test for people at average risk of colon cancer. Positive results from Cologuard indicate that further testing is needed.
What is a Z12 11?
Z12. 11 encounter for screening for malignant neoplasm of colon.
Can Z12 11 be a primary diagnosis?
If the patient presents for a screening colonoscopy and a polyp or any other lesion/diagnosis is found, the primary diagnosis is still going to be Z12. 11, Encounter for screening for malignant neoplasm of colon. The coder should also report the polyp or findings as additional diagnosis codes.
How do you bill for Cologuard?
Contact our Customer Care team at 1-844-870-8870. Cologuard is only billed under CPT code 81528.
What is procedure code 81528?
Group 1CodeDescription81528ONCOLOGY (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 RESULT9 more rows
What does code Z12 31 mean?
For example, Z12. 31 (Encounter for screening mammogram for malignant neoplasm of breast) is the correct code to use when you are ordering a routine mammogram for a patient.
What does Z12 12 mean?
ICD-10 code Z12. 12 for Encounter for screening for malignant neoplasm of rectum is a medical classification as listed by WHO under the range - Factors influencing health status and contact with health services .
What is the ICD-10 code for colon polyp?
ICD-10 code K63. 5 for Polyp of colon is a medical classification as listed by WHO under the range - Diseases of the digestive system .
How do you code a screening colonoscopy turned diagnostic?
If a polyp or lesion is found during the screening procedure, the colonoscopy becomes diagnostic and should be reported with the appropriate diagnostic colonoscopy code (45378-45392). For Medicare patients, the PT modifier would be appended to the code to indicate that this procedure began as a screening test.
Can you code Z12 11 and Z86 010?
Z12. 11 (encounter for screening for malignant neoplasm of colon) Z80. 0 (family history of malignant neoplasm of digestive organs)...Two Sets of Procedure Codes Used for Screening Colonoscopy:Common colorectal screening diagnosis codesICD-10-CMDescriptionZ86.010Personal history of colonic polyps2 more rows•Apr 20, 2022
How do you code colonoscopy after positive cologuard?
If the patient undergoes a colonoscopy for a positive Cologuard and a polyp is found, the coder would select K63. 5 (polyp of colon) as the first-listed diagnosis for the colonoscopy.
What percentage of positive colon guard tests are cancer?
Beside above, what percentage of positive cologuard tests are cancer? The test is about 92 percent sensitive for detecting colon cancer and about 69 percent sensitive for detecting advanced colon polyps. It does have about a 13 percent false positive rate. If a patient has a positive Cologuard test, it is recommended that they then undergo ...
What does a positive colonoscopy mean?
It means that Cologuard detected DNA and/or hemoglobin biomarkers in the stool which are associated with colon cancer or precancer. Patients with a positive result should have a diagnostic colonoscopy.
What is the code for colonoscopy?
To report screening colonoscopy on a patient not considered high risk for colorectal cancer, use HCPCS code G0121 and diagnosis code Z12.11 ( encounter for screening for malignant neoplasm of the colon ).
What is a colonoscopy screening?
As such, “screening” describes a colonoscopy that is routinely performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps. Whether a polyp or cancer is ultimately found does not ...
What is a G0121?
Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen (s) by brushing or washing, with or without colon decompression (separate procedure) G0121 ( colorectal cancer screening; colonoscopy on individual not meeting the criteria for high risk.
What are the global periods for colonoscopy?
Typically, procedure codes with 0, 10 or 90-day global periods include pre-work, intraoperative work, and post-operative work in the Relative Value Units (RVUs) assigned . As a result, CMS’ policy does not allow for payment of an Evaluation and Management (E/M) service prior to a screening colonoscopy. In 2005, the Medicare carrier in Rhode Island explained the policy this way:
Why is diagnosis code ordering important?
Diagnosis Code Ordering is Important for a Screening Procedure turned Diagnostic. When the intent of a visit is screening, and findings result in a diagnostic or therapeutic service, the ordering of the diagnosis codes can affect how payers process the claim.
Is colonoscopy a first dollar service?
Screening colonoscopy is a service with first dollar coverage. A screening test with an A or B rating from the US Preventive Services Task Force, should have no patient due amount, since the Affordable Care Act (ACA) was passed.
Can a patient have a colonoscopy?
The patient has never had a screening colonoscopy. The patient has no history of polyps and none of the patient’s siblings, parents or children has a history of polyps or colon cancer. The patient is eligible for a screening colonoscopy. Reportable procedure and diagnoses include:
What is the diagnosis of a xx-year-old woman presenting for first time screening colonoscopy
Diagnosis: 1.Colorectal screening, average risk and 2. positive Cologuard." In my mind, the two diagnoses contradict each other.
Why is the Cologuard test denied?
Even if you tried to bill as a screening, it should get denied because screening benefits have been used within that time frame.
Is positive cologuard a sign?
You are right Positive cologuard is a sign or symptom so its no longer screening. It would be a false claim to use a screening DX or modifier 33. R19.5 would be the diagnosis that is the reason for ordering the colonoscopy
General Information
CPT codes, descriptions and other data only are copyright 2020 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
Abstract: This article represents local instructions for CMS National Coverage Policy (CMS Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 210.3).
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
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