Frequency Limitations: Effective for dates of service on or after October 9, 2014, colorectal cancer screening using the CologuardTM multitarget sDNA test (G0464) is covered once every 3 years for Medicare beneficiaries that meet all of the following criteria:
• Ages 50 to 85 years,
• Asymptomatic (no signs or symptoms of colorectal disease including but not limited to lower gastrointestinal pain, blood in stool, positive guaiac fecal occult blood test or fecal immunochemical test), and,
• At average risk of developing colorectal cancer (no personal history of adenomatous polyps, colorectal cancer, or inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis;
no family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer).
Effective for claims with dates of service on or after October 9, 2014, providers shall report the following diagnosis codes when submitting claims for the CologuardTM multitarget sDNA test:
ICD-9: V76.41 and V76.51, or,
ICD-10: Z12.11 and Z12.12
To review all requirements of this policy, please see:
CMS NCD listing by Chapter
This policy includes primary and secondary diagnosis code requirements. Please review all requirements of this policy.
The content and format of the following files and/or webpages are
copywritten and the property of Wheaton Partners, LLC - dba CodeMap®. All
recipients of these files agree not to distribute, reproduce and/or use the
information contained within, in any manner not expressly agreed upon by the
user and Wheaton Partners, LLC - dba CodeMap®.
All code-pairs and Medicare coverage information are compiled directly from Center for Medicare and
Medicaid Services (CMS) and Medicare Contractor coverage policies. CodeMap®
has made every reasonable effort to ensure the accuracy of the information
contained. However, the ultimate responsibility for correct
coding and claims submission lies with the provider of services. Both CMS and
Medicare contractor coverage policy information may change at any time.
CodeMap® makes no representation, warranty, or guarantee that this compilation
of coverage policy information is error-free or that the use of this information
will result in Medicare coverage and subsequent payment of claims. Final
coverage and payment of claims are subject to many factors exclusively
controlled by CMS and its contractors.
