Colorectal cancer screening with stool DNA (FIT‑DNA/Cologuard)
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Defines BCBSNC coverage and reimbursement policy for colorectal cancer screening using DNA analysis of stool samples for average‑risk, asymptomatic adults and related billing guidance for providers.
No material clinical or coverage changes in this revision.
Coverage Criteria
Covered screening criteria
Covered when ALL of the following are met
see USPSTF referenced in policy
Policy allows reimbursement every 3 years; testing at intervals shorter than 3 years is not reimbursed
Positive FIT‑DNA results should be followed by diagnostic colonoscopy
Reimbursement is not allowed for colorectal cancer screening using DNA analysis of stool samples when performed for indications other than average‑risk screening. This includes use for diagnostic evaluation, surveillance of known colorectal cancer or adenomatous polyps, inflammatory bowel disease, or any other non–average‑risk purpose.
Reimbursement is not allowed for screening with DNA analysis of stool samples when performed at an interval of less than 3 years.
Use of stool DNA testing for indications other than average‑risk screening or at intervals shorter than 3 years is considered not covered and reimbursement will not be allowed.
Coding and Billing Codes
| 81528 | Oncology (colorectal) screening, quantitative real-time target and signal amplification of 10 DNA markers and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result. |
Provider Actions and Billing Guidance
Billing code guidance — CPT 81528
Use CPT code 81528 when billing for FIT‑DNA (Cologuard); inclusion in the policy’s billing/coding section does not guarantee reimbursement — verify member benefits and eligibility per BCBSNC reimbursement rules.
- Applicable service code listed: 81528
- Inclusion of a code does not guarantee it will be reimbursed; consult BCBSNC administrative reimbursement guidance
Document screening indication and test interval
Ensure claims and documentation explicitly state the screening indication and that the member is average risk; BCBSNC may request supporting records to confirm the indication and interval.
- Document that the individual is asymptomatic and meets the policy definition of average risk.
- Document the date of prior FIT‑DNA testing to confirm the 3‑year interval between tests.
Provide full medical records when requested
Follow BCBSNC requirements for documentation and medical-necessity determinations; include all requested records and any letters of support only when they contain the specific information needed to make the determination.
- BCBSNC may request medical records for determination of medical necessity.
- Letters of support/explanation are not sufficient unless they include all specific information needed for the medical necessity determination.
Denial risk — testing interval < 3 years
Do not bill or expect reimbursement for FIT‑DNA screening performed more frequently than every 3 years; tests at intervals less than 3 years are not reimbursed.
- Reimbursement is not allowed for screening with DNA analysis of stool samples at an interval of less than 3 years.
Non‑covered indications — not average‑risk screening
Do not submit claims for FIT‑DNA (stool DNA) testing for indications other than average‑risk colorectal cancer screening; such uses are not covered and will be denied.
- Reimbursement is not allowed for colorectal cancer screening with DNA analysis of stool samples for all other indications (i.e., indications other than average‑risk screening).
Definitions
Background
Colorectal cancers and advanced precursors shed DNA into stool, and combined fecal immunochemical plus stool DNA assays were developed to detect these markers. However, this policy limits coverage to average‑risk screening at the recommended interval; other uses or more frequent testing are excluded from reimbursement.
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