Preventive and Screening Services (Chapter 18) - Medicare coverage, billing, coding, and payment guidance
Governs Medicare preventive and screening services including coverage, billing, coding, payment, and waiver of cost sharing for a broad set of services and vaccines; affects providers, suppliers, and Medicare Administrative Contractors (MACs).
Policy Summary
PayerAspirus Arise
PolicyPreventive and Screening Services (Chapter 18)
Policy CodePolicy N/A
Change TypeAge threshold & test criteria updates
Effective DateN/A
Next Review DateN/A
Key ActionEnsure blood-based biomarker tests are ordered by a treating physician and performed in a CLIA-certified lab with documented sensitivity/specificity meeting policy thresholds.
Effective for claims with dates of service on or after January 1, 2023, the minimum age for multiple colorectal cancer screening tests is reduced to 45 years and older.
Coverage criteria and performance thresholds specified for blood-based biomarker tests (G0327) including FDA authorization and minimum sensitivity >=74% and specificity >=90%.
Interrupted colonoscopies are paid at one-half the value of inputs and require modifier -53 (professional) or -73/-74 (ASC) on claims; subsequent completed colonoscopy paid normally if coverage conditions met.
100%Medicare payment for listed vaccines
WaiverDeductible waived for USPSTF A/B
WaiverCoinsurance/copayment waived
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45New minimum colorectal screening age
12 moFOBT frequency
>=74% / >=90%Blood-based test thresholds
Coverage criteria and reimbursement rules
Preventive service coverage and waivers
Covered when ALL of the following are met:
IPPE and AWV are paid at 100% and deductible/coinsurance waived when applicable per ACA and MIPPA
Refer to USPSTF grade and statutory provisions
Preventive services must have a USPSTF grade of A or B to qualify for waivers of coinsurance/copayment and deductible
See Preventive Services Table for specific ratings
Part B pays 100% of the Medicare allowed amount for pneumococcal, influenza, hepatitis B, and COVID-19 vaccines and their administration; Part B deductible and coinsurance do not apply for these vaccine-only claims
State law may affect who may administer vaccines
Medicare Part B vaccine coverage criteria
Medicare Part B coverage and special conditions for each vaccine:
Pneumococcal vaccine and administration are covered under Part B; no physician order is required for coverage and beneficiary may receive vaccine upon request
Influenza vaccine and administration are covered under Part B when furnished in compliance with applicable State law; no physician order required for coverage; typically once per flu season
MACs determine reasonableness when frequency issues arise
Hepatitis B vaccine is covered for beneficiaries at high or intermediate risk when ordered by a physician; effective January 1, 2025 a physician's order will no longer be required and mass immunizers may use roster billing for Part B claims
COVID-19 vaccines and administration are covered under Part B when furnished in compliance with applicable State law; effective dates and HCPCS are posted by CMS and administration follows manufacturer guidance during the PHE
Part B deductible and coinsurance do not apply to pneumococcal, influenza, hepatitis B and COVID-19 vaccines and their administration for vaccine-only claims
Coverage criteria and billing stance
Coverage stance and deductible/coinsurance rules for listed vaccines
Medicare covers pneumococcal, influenza, hepatitis B, and COVID-19 vaccines under Part B and pays 100% of the Medicare allowed amount (payment indicator = '1'); deductible indicator = '1' (zero deductible)
Exceptions
Nongovernmental entities that provide immunizations free to all patients must also provide them free to Medicare beneficiaries and may not bill Medicare
Governmental entities may bill Medicare for vaccines provided free to non‑Medicare beneficiaries, except during public health emergencies when government entities providing vaccines at no charge may NOT bill Medicare
Payment basis for certain freestanding facilities (e.g., freestanding renal dialysis facilities) may be lower of actual charge or 95% AWP; provider-based RDFs paid on reasonable cost basis; deductible and coinsurance do not apply
Roster and centralized billing criteria
Criteria for when roster/centralized billing may be used and billing requirements:
Entities that provide immunizations free to all patients may not bill Medicare; entities that charge non-Medicare patients may bill Medicare
Entities that agree to accept assignment may use roster billing for influenza, pneumococcal, COVID-19 (effective Dec 11, 2020) and hepatitis B (effective Jan 1, 2025) and must not collect payment or donations from beneficiaries
Enrollment: entities must enroll via CMS-855 as Mass Immunization Roster Biller to submit roster claims and may only bill for specified vaccines and their administration
Cover document: use a modified CMS-1500 as roster cover with POS 60, 'SEE ATTACHED ROSTER', accept assignment marked, and attach beneficiary roster per instructions
Roster minimum data: roster must include provider name/number, individual date of service per beneficiary, control number, MBI, patient name/address/DOB/sex, and beneficiary signature or 'signature on file'
Coverage and billing criteria
Payment and assignment rules for vaccines and administration
Administration payment rates are based on the MPFS and geographic locality; HCPCS G0008/G0009/G0010 national payment rate set at $30 beginning Jan 1, 2022 (locality-adjusted)
COVID-19 vaccine administration national rate is $40 beginning Jan 1, 2022 through the end of the calendar year in which the PHE ends; thereafter rate will align with other Part B preventive vaccine administration rates
Mandatory assignment: vaccine products require mandatory assignment and providers must accept assignment; for roster/centralized billing providers must also accept assignment for administration and may not collect beneficiary payment
To qualify for centralized billing an entity must provide services in at least three payment localities with at least three different contractors
Roster requirements: roster must include provider name/NPI, date of service per beneficiary, patient name/address/DOB/sex/MBI, beneficiary signature or 'signature on file'; inpatient rosters waive 5-person minimum
Duplicate payment edits and denial behavior
Duplicate-claim edit criteria for influenza and pneumococcal vaccine and administration codes
CWF edits match on MBI, MAC number (Part A or Part B), and date of service together with listed influenza vaccine HCPCS, pneumococcal vaccine HCPCS, or administration codes (G0008/G0009); if matching criteria met the second claim will reject
For influenza product group: if CWF already has a claim with same MBI, same MAC number, same date of service and any one of the listed influenza HCPCS product codes, the second claim will be rejected
For pneumococcal product group: CWF rejects a second claim only when MBI, same MAC number, same date of service and the same pneumococcal HCPCS code all match
For administration codes (G0008/G0009): rejection occurs when MBI, same MAC number, same date of service, and same administration procedure code all match
MACs must deny the second claim and use appropriate MSN/RA messaging
Mammography coverage rules
Mammography coverage and facility certification
Screening mammography is covered under Part B according to statutory age and frequency rules; a physician prescription/referral is not required
Medicare reimburses only FDA‑certified MQSA facilities for screening and diagnostic mammography; A/B MACs verify facility certification via the FDA/MQSA file and may deny or return claims when certification is missing or invalid
Diagnostic criteria
Patient has distinct signs or symptoms indicating mammogram
Patient has a history of breast cancer
Physician judgment indicates mammogram appropriate despite asymptomatic status
Mammography coverage and payment criteria
Payment and coverage rules for screening and diagnostic mammography and tomosynthesis
Screening mammography: no Part B deductible or coinsurance; payment methodology often follows MPFS or lower-of-charge rules depending on setting
Diagnostic mammography: paid under MPFS (per MMA 2003) and deductible/coinsurance may apply depending on setting; outpatient hospital payments use lesser of charge or TC MPFS for relevant diagnostic codes
Screening DBT (77063) must be billed with the primary screening mammogram code (77067); diagnostic DBT (G0279) must be billed with 77065 or 77066; claims missing required pairings or diagnosis may be returned or denied with specified remittance codes
Screening mammography claims must include diagnosis code Z12.31; claims missing this diagnosis are returned as unprocessable or denied
When denying 77063 lines not submitted with required screening diagnosis or G0279 without paired mammogram codes, use CARC 167 / RARC N386 / MSN 14.9 and appropriate Group Code
Coverage and payment criteria by provider setting
Payment decision rules and coverage criteria by setting
Physician/supplier setting: payment = 80% of the lower of actual charge or MPFS amount; coinsurance = 20%; Part B deductible waived for screening mammography
Hospital outpatient setting: screening payment (Revenue code 403) = lesser of charge or TC MPFS for 77067; no deductible or coinsurance for screening; diagnostic bilateral/unilateral paid as lesser of charge or TC MPFS with deductible/coinsurance applying to diagnostic services
CAH options
Standard method: TC paid to A/B MAC (A), PC to A/B MAC (B) based on MPFS; deductible does not apply
Optional (All Inclusive) method: CAH may elect optional method to bill costs and receive alternate payment treatment per CAH rules
Screening pelvic exam and HPV screening coverage criteria
Coverage and billing requirements for screening pelvic examinations and when more frequent exams may be paid.
Routine screening pelvic exam for asymptomatic, low-risk women is payable only after at least 23 months have passed since the month of the last Medicare-covered screening pelvic exam (post‑July 1, 2001 rule)
Pre‑2001 rule: For services furnished Jan 1,1998 through Jun 30,2001: paid once every 35 months for asymptomatic low-risk women who haven't had a paid screening pelvic exam in the preceding 35 months
High‑risk exception: High‑risk beneficiaries may receive screening pelvic exams more frequently when justified by medical history or findings; high‑risk diagnosis codes must be used and frequency may be no more often than once every 11 months after a high‑risk covered exam
Claims must include an appropriate low‑risk or high‑risk ICD‑10 diagnosis code and the screening pelvic exam service must point to that diagnosis; absence or incorrect pointers will cause CWF rejection
Coverage criteria for screening pelvic and prostate services
Coverage and limits for screening pelvic exams and prostate cancer screenings
Screening Pap/pelvic exams are payable once every (2,3) years for beneficiaries without high‑risk factors; denials for frequency use MSN 18.17
Screening PSA and DRE are payable at most once every 12 months for men age 50 and over; counting starts the month after the prior test so at least 11 full months must pass
Prostate screening is covered only for men aged 50 and over; age denials use MSN messages and specified RA/CARCs
DRE (G0102) is bundled into payment for a covered E/M service when furnished the same day (CPT 99201-99456, 99499); payable separately only when it is the sole service or otherwise allowed
Use CARC 119 for frequency denials and CARC 6 / RARC codes for age denials; use CARC 167 when screening diagnosis code is absent (Z12.5 for prostate) as appropriate
Colorectal cancer screening coverage criteria
Medicare covers specified colorectal cancer screening services subject to age, frequency, coding, and setting rules; deductible and coinsurance rules vary by test and scenario.
Minimum age for most colorectal screening services reduced to 45 years effective January 1, 2023
Frequency rules
G0104 (sigmoidoscopy) once every 48 months (effective rules noted)
G0105 (high‑risk colonoscopy) once every 24 months
G0121 (average‑risk screening colonoscopy) once every 10 years (see G0121 criteria) and certain frequency limits are waived when colonoscopy follows a positive non‑invasive stool test with KX modifier
Deductible and coinsurance: no deductible/coinsurance for specified screenings (FOBTs, certain colonoscopies, stool‑ and blood‑based tests); however 25% coinsurance applies for screening colonoscopies (G0105 and G0121) performed in ASCs and some non‑OPPS hospitals per established rules
Multitarget sDNA and blood-based biomarker test coverage criteria
Coverage conditions for multitarget sDNA and blood-based biomarker screening tests
Age requirement: beneficiary must meet minimum age criteria (policy references 45–85 years; see effective dates for reductions to 45)
Symptom and risk: beneficiary must be asymptomatic (no signs/symptoms of colorectal disease) and at average risk (no personal/family history of adenomatous polyps, colorectal cancer, or IBD)
Frequency: multitarget sDNA (Cologuard/81528) and blood‑based biomarker tests (G0327) covered once every 3 years
Laboratory and ordering: blood‑based biomarker tests must be performed in a CLIA‑certified lab and ordered by a treating physician
Test performance: blood‑based biomarker screening tests must have FDA market authorization for screening and meet minimal performance thresholds (sensitivity >=74% and specificity >=90%)
FOBT coverage criteria
Coverage for fecal occult blood testing (FOBT)
Minimum age: FOBT (CPT 82270 / G0328) coverage minimum age reduced to 45 as of Jan 1, 2023
Frequency: covered once every 12 months (at least 11 months after prior covered FOBT)
Test exclusivity: Only one FOBT per 12‑month period is payable: either CPT 82270 (formerly G0107) OR HCPCS G0328, but not both
Ordering: requires written order from attending physician (and, effective 1/27/2014, orders may be from attending PA/NP/CNS)
Coverage for screening colonoscopy on average-risk individuals (G0121)
Frequency: HCPCS G0121 covered once every 10 years (i.e., at least 119 months since prior G0121)
Conditional exclusion: if beneficiary had a prior screening flexible sigmoidoscopy (G0104), the beneficiary must wait 47 months after G0104 before G0121 is payable
Biopsy/change in procedure: if a lesion is detected during the screening colonoscopy resulting in biopsy/removal, bill the appropriate diagnostic colonoscopy code with modifier -PT instead of G0121
ASC facility fee and billing rules
ASC facility payment rules
ASC‑payable services include CPT 45378 (diagnostic colonoscopy), G0105 (high‑risk screening colonoscopy), and G0121 (average‑risk screening colonoscopy) assigned to ASC payment group 2
Coinsurance: a 25% coinsurance applies for colorectal cancer screening colonoscopies (G0105 and G0121) performed in ASCs effective for services on or after Jan 1, 2007
If lesion detected at ASC resulting in biopsy/removal, bill diagnostic colonoscopy code (e.g., CPT 45378) rather than the screening code
Common Working Files edits
CWF edits and claim validation
CWF edits colorectal screening claims for age and frequency standards and validates submitted HCPCS/CPT codes per the colorectal screening code list
Diagnostic mammography, unilateral (includes CAD when performed)
77066
Diagnostic mammography, bilateral (includes CAD when performed); formerly G0204
77067
Screening mammography, bilateral (2-view each breast); formerly G0202
77063
Screening breast tomosynthesis; bilateral (list separately)
G0279
Diagnostic digital breast tomosynthesis (list separately)
Screening mammography diagnosisICD-10Covered
Z12.31
Encounter for screening mammogram for malignant neoplasm of breast
Screening DBT and paired mammogramHCPCSCovered
77063
Screening Digital Breast Tomosynthesis, bilateral
77067
Screening mammography, bilateral (primary service to pair with 77063)
Diagnostic DBT and paired mammogramHCPCSCovered
G0279
Diagnostic digital breast tomosynthesis, unilateral or bilateral
77065
Diagnostic mammography, unilateral (paired with G0279)
77066
Diagnostic mammography, bilateral (paired with G0279)
Diagnostic mammography ICD-10-CM code list (partial section)ICD-10
Multiple ICD-10-CM
Extensive list of diagnostic codes appropriate for diagnostic mammography (malignant neoplasms, benign breast conditions, findings, injuries, history/status codes, etc.)
Primary mammography CPT/HCPCS codesCPTCovered
77067
Screening mammography, digital (or G0202 for older reporting)
77066
Diagnostic mammography, bilateral (G0204 older)
77065
Diagnostic mammography, unilateral (G0206 older)
Diagnosis codes for screening pelvic exams and HPV screeningICD-10Covered
Z01.411
Encounter for gynecological examination (routine) with abnormal findings (low risk list)
Z01.419
Encounter for gynecological examination (routine) without abnormal findings (low risk list)
Z12.4
Encounter for screening for malignant neoplasm of cervix
Z11.51
Screening for HPV (referenced for HPV screening claims)
Z77.9
Other contact with and (suspected) exposures hazardous to health (example high-risk list)
Z92.89
Personal history of other medical treatment (used to indicate presence of certain high risk factors)
Key HCPCS and diagnosis codes for screening servicesmixedCovered
G0101
Cervical/vaginal cancer screening; pelvic and clinical breast examination
G0102
Prostate cancer screening digital rectal examination
G0103
Prostate cancer screening PSA test
0359U
PSA isoform analysis (effective 01/01/23)
Z12.5
Encounter for screening for malignant neoplasm of prostate (ICD-10-CM screening diagnosis)
Colorectal screening codesmixedCovered
CPT 82270 / (former HCPCS G0107)
FOBT; fecal-occult blood tests, 1-3 determinations (CLFS for specific settings)
Stool-based DNA colorectal cancer screening (CLFS)
HCPCS G0327
Blood-based biomarker colorectal cancer screening (effective July 1, 2021)
Screening test codes and replacementsmixedCovered
82270
FOBT, guaiac-based (CPT replacement for G0107)
G0328
Immunoassay FOBT
81528
Cologuard™ multitarget sDNA (replaced G0464)
G0327
Blood-based biomarker colorectal cancer screening test
ASC facility codesmixedCovered
45378
Diagnostic colonoscopy (ASC payment group 2)
G0105
Colonoscopy on high-risk individuals (ASC list)
G0121
Colonoscopy not meeting high-risk criteria (ASC list)
USPSTF Grade Requirement for Cost‑Sharing Waivers
USPSTF grade requirementPreventive services must have a USPSTF grade of A or B to qualify for waiver of coinsurance/copayment and waiver of the Part B deductible (IPPE/AWV and USPSTF A/B services)
Scope of waiverWaiver applies to services listed in section 1861(ddd)(3) and IPPE/AWV when USPSTF grade A or B criteria met
Effective dates note
Provider billing, enrollment, and documentation actions
Note
State vaccination administration rules — follow state laws
State laws governing who may administer preventive vaccinations and coronavirus vaccines and how they are transported vary. Providers must follow state regulations in the jurisdictions where they immunize.
Medicare contractors should instruct physicians, suppliers, and providers to become familiar with state regulations for all vaccines in the areas where they will be immunizing.
Billing Rule
Orders and Provider Authorization
Medicare does not require a physician order for pneumococcal vaccine, and beneficiaries may receive pneumococcal vaccine and its administration upon request without a physician's order or physician supervision. Note: changes to orders/authorization for hepatitis B roster billing become effective Jan 1, 2025.
Pneumococcal vaccine: no physician order required for coverage (Section 1861(s)(10)(A) / 42 CFR 410.57).
Key definitions and terms
Definition: Preventive Services
Definition of preventive servicesPreventive services are those recommended by the USPSTF with a grade of A or B and IPPE/AWV services as specified by statute
Vaccine coverage tie‑insCertain vaccines and their administration are considered Part B preventive services with payment indicators and deductible indicators set accordingly
State law applicabilityState laws govern who may administer vaccines and related transport/handling rules; contractors should instruct providers to follow state regulations
Beneficiary's Share of Payment (Coinsurance/Copayment)
Beneficiary share of paymentCoinsurance represents the beneficiary's percentage share (e.g., 20% under MPFS) and copayment an established amount under OPPS; coinsurance/copayment waived for USPSTF A/B services and specified preventive vaccines
When coinsurance applies
Policy Summary
PayerAspirus Arise
PolicyPreventive and Screening Services (Chapter 18)
Policy CodePolicy N/A
Change TypeAge threshold & test criteria updates
Effective DateN/A
Next Review DateN/A
Key ActionEnsure blood-based biomarker tests are ordered by a treating physician and performed in a CLIA-certified lab with documented sensitivity/specificity meeting policy thresholds.
Institutional and specified provider types may submit institutional claims using appropriate revenue codes (e.g., 0636 for vaccine product lines; 0771 for administration); RHCs/FQHCs have specified instructions effective July 1, 2025
If vaccine and administration are furnished by different entities they should submit separate claims; when vaccines are supplied at no charge submit claim for administration only
When the only service billed is one of these vaccines and/or their administration, MSP utilization edits are bypassed; if other services are on the same claim normal MSP rules apply
MACs may enter missing diagnosis codes or correct incorrect HCPCS codes for listed vaccines when diagnosis and narrative are correct; hepatitis B claims must report referring physician NPI; when no physician orders influenza vaccine provider's own NPI must be in attending physician field
Nonparticipating physicians/suppliers may collect payment for administration from beneficiary and submit an unassigned claim, but drugs/biologicals require mandatory assignment so providers must accept assignment for vaccines
Assignment: drugs/biologicals (vaccine products) require mandatory assignment; providers must accept assignment for vaccines and, for roster/centralized billing, accept assignment for administration as well
Administration payment amounts are locality-adjusted and tied to MPFS history; national baseline rates established (e.g., G0008/G0009/G0010 national rate $30 beginning Jan 1, 2022) and COVID-19 administration $40 national rate during the PHE period
Centralized billing eligibility: to qualify operate in at least three payment localities and enroll with the designated contractor (Novitas); centralized billers must submit electronic roster bills and accept assignment
Centralized billers must include ZIP code of service and billing provider/supplier contact info and NPI on roster claims to determine payment locality
Payment rates vary by locality and are based on the MPFS; designated administration codes and national baselines are available from CMS (G0008/G0009/G0010 national rate referenced)
Record retention: providers must retain roster bills with beneficiary signatures per Medicare record retention rules
MAC processing: MACs must create one claim per beneficiary from roster bills, may fill missing CMS-1500 fields from the roster, and should return as unprocessable (not deny) improperly used roster bills
Centralized billing submissions are electronic only; paper claims are not accepted for centralized roster billing
CWF duplicate edits and reject behavior: CWF rejects duplicate Part A roster claims when same MAC number, MBI, date, and matching vaccine/admin HCPCS appear; specific reject codes returned and MACs must deny duplicate claims
Centralized billers must retain roster bills with signatures and provide beneficiary notification about processing contractor; designated contractor must have correct service location ZIP to determine payment locality
Centralized roster claims must be submitted electronically in approved format; paper claims are not accepted
Claims identified for special processing use Demonstration/Special Processing Number 39 in CWF for roster/centralized processing
When services are furnished under arrangements, the arranging provider must ensure the performing facility has valid MQSA certification
SNF: screening mammography payment equals lower of charge or TC MPFS for 77067; no deductible; coinsurance applies where specified; diagnostic payments follow lower-of-charge MPFS rules with deductible/coinsurance
A/B MACs use the FDA MQSA file to validate facility certification; claims with missing or mismatched certification numbers will be returned or denied
Coding and payment setting: some tests paid under MPFS, others under CLFS or OPPS depending on the test and setting; stool/blood‑based tests (81528, G0327) have CLFS/MPFS payment guidance
Interrupted colonoscopy: when colonoscopy cannot be completed submit professional claim with modifier -53 and ASC facility claims with -73/-74; interrupted colonoscopy paid at one‑half value and documentation must be retained
CWF edits validate age, frequency and HCPCS/CPT codes for colorectal screening claims; see CWF edits for list of validated codes
Diagnosis coding: claims for multitarget sDNA and blood‑based tests must report an appropriate screening diagnosis (Z12.11 or Z12.12)
Deductible waiver effective for services furnished on or after January 1, 2011 (IPPE deductible waived effective Jan 1, 2009 per MIPPA)
Payment Rate Thresholds
G0008/G0009/G0010 national rateNational payment rate for HCPCS G0008, G0009, and G0010 set at $30 (beginning January 1, 2022) and adjusted by MPFS Geographic Practice Cost Indices (GPCI)
COVID‑19 administration rate (PHE)During the PHE the national payment rate for COVID‑19 vaccine administration is $40 (locality‑adjusted by GPCI); after the PHE it will align with other Part B preventive vaccine administration rates
Locality adjustmentAll national administration rates are adjusted based on MPFS GPCIs; locality‑adjusted rates available on CMS website
Centralized and Roster Billing Submission
Electronic submission required for centralized billingCentralized billers must submit roster bills electronically in CMS‑approved electronic format; paper claims will not be accepted
Roster billing formSimplified roster billing uses a modified CMS‑1500 cover form with an attached roster listing beneficiaries (Form CMS‑1450 procedures noted)
MAC selectionThe contractor assigned to process centralized billing (specialty contractor) is chosen by CMS (Novitas currently) and centralized billers must follow that contractor's electronic billing requirements
Roster Billing Minimums for Mass Immunizers
Roster minimum for mass immunizersTo qualify for roster billing, immunizations of at least 5 beneficiaries on the same date are required (this 5‑person minimum is waived for inpatient Part B roster billing)
Roster required data elementsRoster must include provider name/NPI, date of service per beneficiary, patient name/address/DOB/sex/MBI, and beneficiary signature or 'signature on file'
ApplicabilitySimplified roster billing applies to mass immunizers for influenza, pneumococcal, and COVID‑19 vaccines (and hepatitis B effective 1/1/2025) when enrollment and assignment requirements are met
Centralized Biller Locality Requirement
Centralized billing locality requirementTo qualify for centralized billing, the provider must operate in at least 3 payment localities served by at least 3 different MACs
State licensure and enrollmentCentralized billers must be properly licensed in states where vaccinations are given and enroll with Medicare (CMS‑855) or follow contractor application procedures
Payment locality reportingCentralized billers must report the service ZIP code/location on roster claims so payment is made based on the locality where the service was provided
Billing Pair Requirements for DBT
77063 billing pairHCPCS 77063 (screening DBT) must be billed in conjunction with primary screening mammogram code 77067; 77063 billed alone will be returned/denied
G0279 billing pairHCPCS G0279 (diagnostic DBT) must be billed with primary diagnostic mammogram code 77065 or 77066; G0279 billed alone will be returned/denied
Claim handlingA/B MACs return or deny DBT lines not submitted with the paired primary mammogram code and use specified remittance messaging for denials
CAH Optional Method Professional Payment Multiplier
CAH optional method multiplierIf a CAH elects the Optional (All‑Inclusive) Method, A/B MAC (A) pays the professional component at 115% of the allowed amount (effectively 92% of the lower of charge or MPFS amount after the 80% base calculation)
Billing under optional methodCAHs electing the optional method bill TOB 85X with revenue code 0403 for TC and separate lines for the professional component using appropriate revenue codes
Effective periods and cost reportingOptional method is available for cost reporting periods beginning on or after Oct 1, 2001 with specified implementation details for dates of service
HPV Screening Frequency Threshold
HPV screening frequency thresholdHPV screening (G0476) is payable only if at least 59 months have elapsed since the date of the last screening (treated as a 5‑year limit; at least 4 years and 11 months must pass)
Age requirement and diagnosis codesHPV screening claims must meet age criteria (commonly ages 30–65) and include appropriate ICD‑10 codes (e.g., Z11.51, Z01.411, Z01.419) to avoid denial messaging
Denial messagingWhen denying G0476 for inappropriate frequency use CARC 119 and RARC N386 with Group Code PR or CO as applicable
High‑Risk Pelvic Exam Frequency Limit
High‑risk pelvic exam frequency limitBeneficiaries identified as high risk may receive screening pelvic exams more frequently, but not more often than once every 11 months after the month of the last covered high‑risk exam
High‑risk coding requirementProviders must use appropriate high‑risk ICD‑10‑CM diagnosis codes on claims to indicate eligibility for more frequent screening
Counting methodFrequency counts begin the month after the month in which the previous exam was performed (start counts in the following month)
Prostate Screening Frequency Calculation
Prostate screening frequency calculationCount begins the month after the prior PSA/DRE test; screening PSA/DRE payable no more than once every 12 months (i.e., at least 11 full months must pass before next payable test)
Age requirementScreening PSA/DRE covered only for men aged 50 and over (use ICD‑10 Z12.5 for screening when applicable)
CWF editsCWF enforces edits for age, frequency, sex, and valid HCPCS codes for prostate screening claims
Summary of Frequency and Age Rules (Examples)
Frequency and age rules vary by procedureExamples: G0105 (screening colonoscopy — high risk) frequency and G0104 (sigmoidoscopy) once every 48 months; FOBT (82270/G0328) once every 12 months; minimum screening age reduced to 45 effective Jan 1, 2023
FOBT mutual exclusionMedicare pays only one FOBT per year: either CPT 82270 (or its replacement) or HCPCS G0328, but not both
KX modifier exceptionFrequency limits for screening colonoscopy (G0105/G0121) do not apply when procedure follows a positive non‑invasive stool‑based test and the screening colonoscopy claim includes the KX modifier
Blood‑Based Biomarker Test Performance Thresholds
Blood‑based biomarker performance thresholdsCovered blood‑based biomarker colorectal screening tests must have FDA market authorization and demonstrate sensitivity >= 74% and specificity >= 90% in pivotal studies
Ordering and lab requirementsTest must be ordered by a treating physician and performed in a CLIA‑certified laboratory; diagnosis Z12.11 or Z12.12 must be reported on claims for G0327
Frequency and ageBlood‑based biomarker tests covered once every 3 years; minimum age reduced to 45 effective Jan 1, 2023
FOBT Frequency and Ordering
FOBT frequencyScreening FOBT (CPT 82270 or HCPCS G0328) payable once every 12 months — i.e., at least 11 months must pass following the month of the prior covered FOBT
Ordering requirementFOBT requires a written order from the beneficiary's attending physician (and effective Jan 27, 2014, orders from PA/NP/CNS are acceptable)
Age minimum updateMinimum age for FOBT reduced to 45 years effective January 1, 2023
Effective Jan 1, 2025 roster billing is available for hepatitis B vaccinations; centralized billing/enrollment rules apply.
Billing Rule
MSP and Claim Edits — vaccine-only claims bypass MSP edits
MSP utilization edits in CWF are bypassed when the only services on the claim are pneumococcal, influenza, hepatitis B or COVID-19 vaccines and/or their administration. If other services are billed on the same claim, MSP rules and first-claim development apply and the primary payer must be billed when appropriate.
Waiver applies only when vaccine and/or administration are the sole services on the claim.
First claim development alerts are not generated for standalone vaccine claims; they are performed if other services are submitted on the same claim.
Documentation Required
Claims with missing or incorrect data — MACs may correct and continue processing
If a vaccine claim is missing a diagnosis code or contains an incorrect HCPCS but the narrative supports the vaccine, MACs may add the appropriate diagnosis or correct the HCPCS and continue processing. Claims for hepatitis B vaccinations must report the referring physician's NPI. For influenza claims without a physician order, report the provider's own NPI in the attending physician field as required.
Contractors may enter a missing diagnosis for pneumococcal, hepatitis B, influenza, or COVID-19 vaccinations and process the claim.
If narrative and diagnosis support the service but HCPCS is incorrect, MACs may correct the HCPCS and pay the claim.
Hepatitis B vaccination claims must report the referring physician NPI.
If a physician does not order influenza vaccine, the provider's own NPI must be reported in the attending physician field.
Billing Rule
Roster billing requirements for mass immunizers
Entities performing mass immunizations may use simplified roster billing and must accept assignment; they may not collect payment or require beneficiaries to pay or file claims. Roster billers cannot bill for non-vaccine services using this enrollment and must retain beneficiary rosters and signatures per Medicare record retention rules.
Roster billing available for influenza, pneumococcal, COVID-19 (since Dec 11, 2020) and hepatitis B (effective Jan 1, 2025).
Entities using roster billing must accept assignment and may not collect any payment or donation from beneficiaries.
Roster billers must retain roster bills with beneficiary signatures consistent with Medicare record retention requirements.
Prior Authorization
Enrollment and assignment requirements
Entities providing mass immunization services may enroll as a Mass Immunization Roster Biller (Form CMS-855). Centralized billers must meet additional criteria (operate in at least three payment localities processed by different MACs) and must agree to accept assignment and submit claims electronically.
Enroll by completing CMS-855 as provider type 'Mass Immunization Roster Biller'.
Centralized billers must operate in ≥3 payment localities (three different MACs) and apply in writing.
Centralized billers must be properly licensed in states where vaccinations occur, accept assignment, submit electronic roster claims, and report service facility location for geographic payment.
Billing Rule
Roster bill required information for centralized billing
Centralized billers must include beneficiary ZIP code of where service was rendered, billing provider/supplier name, address, ZIP code, telephone number, and the billing provider or group's NPI on roster claims so MACs can determine payment locality and send MSNs correctly.
Required on claim: service ZIP code, billing provider/supplier name, address, ZIP code, telephone number, and billing provider/group NPI.
Centralized billers must provide beneficiary address to enable Part B MAC to send the Medicare Summary Notice (MSN).
Part B MAC should be informed in writing which MAC will process the claim; provide beneficiaries a written notice naming the processing Part B MAC.
Billing Rule
Mandatory assignment and billing responsibility for centralized billers
Centralized billers must accept assignment and may not charge beneficiaries or collect payment up-front; providers are required to file claims on behalf of beneficiaries. Centralized billers must submit roster claims electronically and follow payment locality/geographic adjustment rules.
Centralized billers must accept assignment — beneficiaries cannot incur out-of-pocket costs for covered vaccines.
Paper claims for centralized roster billing are not accepted; claims must be submitted in CMS-approved electronic format.
Payment rates for vaccine administration are geographically adjusted and determined by Medicare fee schedule or standard drug/biologic reimbursement methods.
Documentation Required
Enrollment, documentation retention, and annual verification
Centralized billers must enroll (CMS-855), be properly licensed, retain documentation (rosters/signatures), and annually verify understanding of coverage and roster warning language with the designated Part B MAC. Influenza/pneumococcal centralized billers do not need separate enrollment to administer COVID-19 vaccine.
Obtain provider number from designated Part B MAC for centralized billing purposes (in addition to any existing Medicare provider number).
Centralized billers must contact the designated Part B MAC annually to verify understanding of coverage and obtain required warning language for roster bills.
Centralized billers must include annual program estimates and operational details when requesting ongoing approval (see centralized billing criteria list).
Billing Rule
Duplicate claim prevention for influenza and pneumococcal vaccines
CWF duplicate-payment edits prevent multiple payments for influenza and pneumococcal vaccines and their administration by matching MBI, MAC, date of service, and vaccine/admin HCPCS. MACs must deny the second claim and return specific reject codes; centralized billers are subject to the same edits to avoid cross-MAC duplicates.
CWF edits by line item: match on MAC number, MBI, date of service, vaccine HCPCS (influenza or pneumococcal) and administration G0008/G0009 to reject duplicates.
If a second claim matches on the specified elements, CWF returns a specific reject code and MACs must deny the second claim using duplicate-claim messaging.
Edits apply across MACs and to centralized billers to prevent duplicate payment between contractors.
Documentation Required
Diagnosis code requirement for screening mammography (Z12.31)
Screening mammography claims must include diagnosis code Z12.31. A/B MACs (B) may not add the code if missing; claims without this diagnosis should be returned as unprocessable (assigned claims) or denied (unassigned claims). For institutional claims where screening mammography is the only service, report Z12.31 as the principal diagnosis.
Report ICD-10-CM Z12.31 on screening mammography claims; A/B MACs (B) will return claims with no diagnosis as unprocessable.
For institutional claims with screening mammography as the only service, report Z12.31 in Principal Diagnosis field.
Providers must follow ASC X12 837 and paper form reporting instructions for diagnosis placement.
Billing Rule
Screening digital breast tomosynthesis billing rule
Screening digital breast tomosynthesis (77063) must be billed with the primary screening mammogram code 77067 (for dates of service Jan 1, 2018 and later). Claims containing 77063 without 77067 will be returned/denied; if paired mammogram fails age/frequency edits in CWF both services may be rejected.
For DOS Jan 1, 2018 and later, 77063 must be submitted with 77067.
A/B MACs (A) return claims with 77063 not accompanied by 77067; A/B MACs (B) deny payment for 77063 when billed without 77067.
If 77063 is billed with 77067 and the screening mammogram fails age/frequency edits, CWF will reject both services.
Billing Rule
Diagnostic digital breast tomosynthesis billing rule
Diagnostic digital breast tomosynthesis (G0279) must be billed with the appropriate diagnostic mammogram code: for DOS Jan 1, 2018 and later submit G0279 with 77065 or 77066. Claims with G0279 that are not paired with the required primary mammogram code will be returned or denied. Facility TOB and revenue code requirements apply for G0279 institutional claims.
For DOS Jan 1, 2018 and later, G0279 must be submitted with 77065 or 77066.
Claims with G0279 without the required accompanying mammogram will be denied or returned.
Diagnostic tomosynthesis claims submitted with an improper revenue code (not 0401, 096X, 097X, or 098X) or TOB (not 12X,13X,22X,23X,85X) will be returned to providers.
Billing Rule
HCPCS modifier and billing entity requirements for mammography
When billing mammography services, use appropriate HCPCS modifiers for component billing: use -TC for the technical component, -26 for the professional component, and leave modifier position #1 blank for global screening mammography billing. Ensure facility certification numbers and other mammography-specific data are on the claim as required by A/B MAC (B).
Entities billing globally for screening mammography should leave modifier position #1 blank.
Technical component (TC) use modifier '-TC'; professional component billed separately use modifier '-26'.
Ensure the 6-digit FDA-assigned mammography certification number is included on the claim (A/B MAC (B) requirement).
Denial Risk
HPV screening denial messaging and financial assignment rules
When denying HPV screening (G0476) for age, frequency, or missing/incorrect diagnosis, use the specified CARC/RARC/MSN messages and assign financial responsibility per modifier on claim: CARC 119 or other codes as detailed; follow MSN messaging guidance. Use Group Code PR if GA modifier indicates ABN on file, or CO if GZ indicates no ABN.
If denying G0476 for frequency (more than once in 5 years) use CARC 119 and RARC N386; assign PR if GA modifier present, CO if GZ present.
If denying G0476 for beneficiary not between ages 30-65, use the specified MSN messaging in section 30.8.
When applying denials, follow the keyed remittance advice codes and MSN messages referenced in policy.
Documentation Required
Screening pelvic exam billing to A/B MAC (B) — use -25 when E/M is separate
A covered E/M visit and code G0101 (screening pelvic exam) may be reported on the same date if the E/M is separately identifiable; report modifier -25 on the E/M and document the separately identifiable service. For institutional billing and RHC/FQHC rules, follow the bill type and revenue code instructions.
When an E/M is separately identifiable on same date as G0101, report modifier '-25' with the E/M and document.
RHC/FQHC professional component billing: bill A/B MAC (A) under bill type 71X or 73X with revenue code 052X; technical component billed to A/B MAC (B) when applicable.
Applicable bill types for screening pelvic exam: 12X,13X,22X,23X,85X; revenue code 0770.
Billing Rule
Prostate screening and RHC/FQHC billing rules
Prostate screening billing: G0102 (DRE) is bundled into same-day E/M payments and is payable separately only when it's the sole service or part of noncovered service. PSA and DRE have specific bill types and revenue codes; RHCs/FQHCs bill the professional component as RHC/FQHC service per guidance.
DRE (G0102) bundled into covered E/M (CPT 99201-99456, 99499) when furnished same day; payable separately only if sole service or otherwise noncovered.
G0102 TOS and revenue code: A/B MAC (B) TOS=1; A/B MAC (A) revenue code=0770.
G0103 (screening PSA) TOS=5; A/B MAC (A) revenue code=030X. RHC/FQHC billing rules apply for professional components.
Denial Risk
Remittance messages and denial codes — use specified CARC/RARC/MSN
Use the remittance advice and claim adjustment codes specified when denying mammography or prostate screening services for age, frequency, or missing diagnosis. Examples: CARC 167 / RARC N386 / MSN 14.9 for 77063 issues; CARC 6 and Remark M82 for prostate screening under-age denials; CARC 119 for frequency denials; CARC 167 with RARC N386 for missing Z12.5 on prostate claims.
For 77063 denied when not submitted with required diagnosis use CARC 167, RARC N386, MSN 14.9; Group Code PR if GA modifier present, CO if GZ modifier present.
For prostate screening denied due to age <50 use ASC X12 835 CARC 6 and remark code M82.
For frequency denials use CARC 119 (benefit maximum reached) and applicable remark codes (e.g., M83 for Pap/Pelvic).
Billing Rule
Interrupted colonoscopy billing and modifiers
When a colonoscopy is attempted but interrupted, professional claims must append modifier -53 to indicate an interrupted procedure and will be paid at one-half the value of the inputs. ASC facility facility claims should use modifier -73 or -74 as appropriate; payment methodology is consistent with diagnostic colonoscopy payment rules.
Professional providers: suffix colonoscopy codes with modifier '-53' for interrupted procedures; payment = 50% of inputs.
ASC facility claims: use modifier '-73' or '-74' as appropriate and payment is half the input value for interrupted procedures.
Maintain adequate medical record documentation to support the incomplete procedure if requested by MACs.
Prior Authorization
Blood-based biomarker test authorization and ordering
Blood-based biomarker colorectal cancer screening tests (HCPCS G0327) are covered once every 3 years when performed in a CLIA-certified lab, ordered by a treating physician, beneficiary meets age and risk criteria, and the test has FDA authorization and minimum performance thresholds. Submit an appropriate screening diagnosis code (Z12.11 or Z12.12) — minimum screening age was reduced to 45 effective Jan 1, 2023.
Coverage criteria: CLIA-certified lab, ordered by treating physician, FDA market authorization for screening indication, sensitivity ≥74% and specificity ≥90% per pivotal studies.
Patient criteria: age 45-85 (effective Jan 1, 2023 minimum age = 45), asymptomatic, average risk for colorectal cancer.
Report at least ONE screening diagnosis: Z12.11 (colon) or Z12.12 (rectum) on G0327 claims. Frequency: once every 3 years.
Coinsurance may apply for certain diagnostic or non‑preventive services depending on setting and payment method
Limiting charge and assignmentMandatory assignment applies for vaccine products (drugs/biologics); limiting charge cannot be applied to these vaccines and their administration
Deductible Waiver for Preventive Vaccines
Deductible waiver for preventive vaccinesPart B deductible is waived for preventive services with USPSTF grade A/B and for listed vaccines (pneumococcal, influenza, hepatitis B, COVID‑19); CWF indicators reflect zero deductible (Deductible Indicator = '1')
Implementation datesDeductible waiver for preventive services effective Jan 1, 2011 (IPPE deductible waived Jan 1, 2009 per MIPPA)
CWF flagsCWF uses Payment and Deductible indicators (e.g., Payment Indicator = '1' means 100% payment; Deductible Indicator = '1' means zero deductible) for vaccine records
ICD‑10 Code Z23 for Immunization Encounters
Z23 diagnosis codeICD‑10‑CM code Z23 ('Encounter for immunization') must be used for vaccine immunization encounters, including COVID‑19; all vaccine claims must include appropriate diagnosis code, procedure, and admin code
Vaccine‑only claimsIf the sole purpose of the visit is vaccination, Z23 may be used as the applicable diagnosis code on the claim
Claims processing noteClaims missing required diagnosis/procedure/admin codes may not process correctly and should be completed as specified
Payment Indicator Definition
Payment indicator meaningPayment Indicator = '1' indicates 100 percent payment for the listed vaccine (CWF/MAC Part B indicators)
Deductible indicator relationDeductible Indicator = '1' indicates zero deductible for the vaccine record; '0' would indicate deductible applies
Type of service flagType of service field contains 'V' for pneumococcal, influenza, and COVID‑19 vaccine entries (MAC record to CWF)
Deductible Indicator Definition
Deductible indicator '1'A Deductible Indicator value of '1' in the MAC (Part B) CWF record represents a zero deductible for the listed vaccine
Usage contextThis indicator is applied for pneumococcal, influenza, hepatitis B, and COVID‑19 vaccine records in CWF to reflect waived deductible
Contrast value '0'A Deductible Indicator of '0' indicates that deductible applies (e.g., typical non‑preventive services)
Place of Service (POS) Codes for Vaccination Billing
POS 60Use POS 60 (Mass Immunization Center) on preprinted CMS‑1500s for simplified roster billing regardless of the physical site where vaccines are given
POS 71POS 71 reserved for State or Local Public Health Clinic (PHC) use; POS 71 not used for individual offices/entities other than PHCs
POS 99Use POS 99 (Other Unlisted Facility) when no other POS code applies (e.g., mobile unit not affiliated with PHC)
Mass Immunization Roster Biller (Provider Type)
Mass Immunization Roster Biller definitionProvider type for entities that enroll (CMS‑855) to submit roster claims and may bill only for pneumococcal, influenza, hepatitis B, and COVID‑19 vaccines and their administration
Billing limitationEntities enrolled as Mass Immunization Roster Biller may not bill Medicare for services other than the specified vaccines and administration
Always accept assignmentClaims submitted by Mass Immunization Roster Billers are reimbursed at the assigned payment rate and the provider must accept assignment
Centralized Biller (Definition)
Centralized biller definitionProvider authorized to submit all influenza, pneumococcal, and COVID‑19 vaccination claims to a single designated MAC; must operate in 3+ payment localities, accept assignment, roster bill, and submit electronically
Enrollment and contractor selectionCentralized billers enroll/apply and the processing contractor is assigned by CMS (Novitas currently); centralized billers must be licensed in service states
Claims processed by single MACCentralized billers send all qualifying vaccination claims to one MAC for payment regardless of where vaccinations were administered; payment is based on the service locality reported
Roster Billing — Operational Summary
Roster billing process summarySimplified roster billing uses a modified CMS‑1500 cover document with an attached beneficiary roster listing multiple beneficiaries and variable claim data; MACs create individual claims from the roster
Roster content requirementsRoster must include provider name/NPI, date of service for each beneficiary, MBI, name/address/DOB/sex, control number, and beneficiary signature or signature on file
Inpatient roster exceptionFor inpatient Part B roster billing (TOB 12x/22x) additional admission data elements are required and the 5‑person minimum may be waived
MQSA Certification Requirement for Mammography Facilities
MQSA certification requirementFacilities providing screening and diagnostic mammography must have an FDA‑issued MQSA certificate; A/B MACs receive weekly MQSA file data to validate facility certification
MQSA file contentsMQSA file includes facility name, 6‑position certification number, film/digital indicators, effective/expiration dates, and termination flag ('T')
Payment limitationMedicare will reimburse only FDA‑certified mammography centers for mammography services; claims from non‑certified facilities are denied
Screening Mammography Diagnosis Coding (Z12.31)
Z12.31 requirement for screening mammographyICD‑10‑CM code Z12.31 (Encounter for screening mammogram) must be reported on screening mammography claims; A/B MACs (B) may not populate the code for providers and claims missing it are returned/denied
Claim field locationsFor professional claims include Z12.31 in field 21/24E or Loop 2300 of electronic professional claim; institutional claims report Z12.31 as principal diagnosis when screening mammogram is sole service
Denial/return behaviorScreening mammography claims with no diagnosis code are returned as unprocessable for assigned claims or denied for unassigned claims
Mammography: Professional, Technical and Global Components
Professional component definitionProfessional component (PC) refers to the physician's interpretation and related professional services for mammography
Technical component definitionTechnical component (TC) includes all other services (equipment, technologist, processing) associated with mammography
Global service definitionGlobal service includes both professional and technical components billed together (global billing not permitted in outpatient departments except CAHs electing optional method)
CAH Optional (All‑Inclusive) Method
Optional (All‑Inclusive) Method (CAH)CAH Optional Method allows CAHs to elect payment by reasonable cost for facility services and receive 115% of the allowed amount for the professional component when applicable
Billing under optional methodCAHs electing optional method bill A/B MAC (A) with TOB 85X and revenue code 0403 for the technical component and separate lines for the professional component (96X/97X/98X)
Effect on payment calculationsWhen CAH elects optional method, the A/B MAC (A) professional payment is 115% of allowed amount (stated as 92% of lower of charge or MPFS after 80% base in examples)
MQSA File — Verification and Use
MQSA file usageThe FDA MQSA file is used weekly by A/B MACs to verify facility certification and determine film vs digital certification for appropriate payment levels
Digital vs film indicatorsMQSA file indicates film certification (record type=1) or digital certification (record type=2) so MPFS/digital payment differentials can be applied
Certification number matchingA/B MACs (B) match the facility's 6‑digit MQSA certification number on the claim to the MQSA file; mismatches result in claim return/denial
Screening Pelvic Examination — Definition and Components
Screening pelvic exam definitionA Medicare‑covered clinical screening pelvic exam (including clinical breast exam) should include at least 7 of 11 specified elements (breast inspection/palpation, DRE, external genitalia, urethral meatus, urethra, bladder, vagina, cervix, uterus, adnexa/parametria, anus/perineum)
Provider types authorizedExam must be performed by MD/DO, certified nurse midwife, PA, NP, or clinical nurse specialist authorized under State law to perform the exam
Ordering and frequency contextThis exam does not require a physician order and has frequency limitations (routine vs high‑risk) as detailed in policy
MSN 15.19 / 15.20 — Standard Messages
MSN 15.19 / 15.20 messagesMSN 15.19 and MSN 15.20 are standard messages advising that an LCD or specified policies were used in the claim decision and beneficiaries can request a copy
Usage when denying HPV linesMSN 15.19/15.20 used when denying HPV screening (G0476) lines for missing/incorrect diagnosis codes or other coverage reasons
Spanish language availabilitySpanish versions of these MSN messages are provided in policy text for beneficiary notices
Screening DRE and PSA Definitions
Screening digital rectal exam definitionScreening DRE is a clinical prostate exam performed by authorized clinicians to detect nodules or abnormalities and must be performed by authorized practitioners
Screening PSA definitionScreening PSA measures prostate specific antigen in blood and must be ordered by the beneficiary's physician (or authorized PA/NP/CNS/CNM) who will explain results
Bundling rule noteDRE (G0102) is bundled into payment for a covered E/M service when furnished same day; payable separately only if sole service or meeting coverage conditions
Interrupted Colonoscopy — Definition and Billing Modifiers
Interrupted colonoscopy definition and modifiersAn interrupted colonoscopy is a covered colonoscopy attempted but not completed due to extenuating circumstances; professional services use modifier -53 and ASCs use -73/-74
Payment for interrupted procedureA/B MAC (B) pays interrupted colonoscopy at one‑half the value of inputs; subsequent completed colonoscopy is paid normally if coverage conditions met
Documentation requirementProviders must maintain adequate medical record documentation to support the interrupted procedure for MAC review
KX Modifier — Screening Colonoscopy Following Positive Stool Test
KX modifier purposeKX modifier is used by the furnishing practitioner to identify a screening colonoscopy that follows a positive non‑invasive stool‑based test so frequency limitations do not apply
When to useApply KX on screening colonoscopy claim when it follows a positive non‑invasive stool test (e.g., CPT 82270/G0328 or stool DNA) to bypass standard frequency edits
Regulatory referenceThis scenario is identified per 42 CFR 410.37(k) and policy guidance for claims effective Jan 1, 2023 and later
Definition: High Risk for Colorectal Cancer
High‑risk for colorectal cancer definitionHigh‑risk individuals include those with a close relative with colorectal cancer or adenomatous polyp, family history of familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer, personal history of adenomatous polyps or colorectal cancer, or inflammatory bowel disease (Crohn's or ulcerative colitis)
Implication for frequencyHigh‑risk status affects screening intervals (e.g., G0105 frequency) and coding to indicate eligibility for more frequent screening
Use in claimsProviders should document high‑risk criteria in medical records and use appropriate ICD‑10‑CM codes when billing to support coverage and frequency exceptions