2023 Coding Updates: CMS Screening Colonoscopy Changes

Effective Jan. 1, 2023, CMS made important changes to the colorectal cancer screening (CRC) guidelines. In addition to lowering the minimum age for Medicare-covered CRC from 50 to 45, there was also an important change tied to a colonoscopy following a positive result from a non-invasive stool-based CRC test, such as Cologuard.

Previously, if a patient had a positive stool-based CRC test, the subsequent colonoscopy was coded as a diagnostic test. As per the AHA's issue of the Coding Clinic Advisor from the first quarter of 2019:

Q: A patient underwent a colonoscopy because of a positive Cologuard test. The colonoscopy demonstrated no abnormal findings. What is the appropriate diagnosis code for this encounter?

A: Assign code R19.5, Other fecal abnormalities, for the abnormal Cologuard test findings. The Official Guidelines for Coding and Reporting state, “For patients receiving diagnostic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit. Codes for other diagnoses (e.g., chronic conditions) may be sequenced as additional diagnoses.”

Revised Guidelines

CMS has now stated the follow-on colonoscopy is an important part of the screening process and patient cost sharing will not apply. Frequency limitations for screening colonoscopies also won’t apply to the follow-on screening colonoscopy that follows a positive test result from a stool-based sample.

To differentiate the follow-on colonoscopy from other services, a KX modifier should be appended to the appropriate CPT code for all Medicare claims. Check with your commercial carriers for any specific requirements they may have.

For more information, refer to MLN Matters article MM13017.