Regarded as the third most common cancer diagnosed in the United States (as per American Cancer Society (ACS) estimates), colorectal cancer begins in the large intestine or colon – the final part of the digestive tract. Also known as bowel cancer, colon cancer, or rectal cancer, the condition often begins as small, clumps of cells called polyps that form on the inside of the colon or rectum. Polyps may be small and produce few or no symptoms at all in certain cases. These polyps may be benign, or non-cancerous, or malignant. In due course, some of these polyps can become cancerous, if not removed. The possible chance of a polyp becoming cancerous may depend on its specific type. As these polyps produce few or no symptoms, physicians recommend regular screening tests to help prevent the occurrence of colon cancer by identifying the growth of polyps and removing them before they spread to other parts of the body. Treatment for this condition involves a combination of modalities like – chemotherapy, radiotherapy and surgery. Oncologists and other specialists providing treatment for cancer patients can rely on reputable medical billing companies to meet their claim submission tasks and thus receive correct reimbursement on time.

As per estimates from the American Cancer Society (ACS), around 100,000 new cases of colon cancer and 45,000 new cases of rectal cancer will be diagnosed in the US in the year 2021. Approximately 53,000 people in this country will die from the disease this year. It is estimated that the risk of developing this condition is about 1 in 23 in men and 1 in 25 in women. In general, physicians are unsure about the exact factors that cause this type of cancer. It begins when healthy cells in the colon develop changes (mutations) in their DNA. Healthy cells grow and divide in an orderly way to keep your body functioning normally. But when a cell’s DNA is damaged and becomes cancerous, cells continue to divide and accumulate, forming a tumor. However, several potential factors like – family history or genetic factors, age, lifestyle related factors (such as smoking, diet, physical inactivity, obesity or alcohol use) could increase the risks associated with the condition.

Signs and Symptoms of Colorectal Cancer

There are different signs and symptoms associated with the condition, which again may depend on the causes and the severity of the condition. Some of the common symptoms of colon cancer include – unexplained weight loss, rectal bleeding or blood in the stools, persistent abdominal discomfort, change in bowel habits, cramping or stomach discomfort, vomiting, diarrhea and a feeling of weakness or fatigue. However, the type and intensity of symptoms can vary from person to person.

Guidelines for Colon Cancer Screening Services

For most cases, colon cancers are preventable – and if detected at an early stage, it’s less likely to cause death. This is where the prominent role of routine screening comes into play. In fact, detecting any type of cancer at an early stage allows for more treatment option and more successful outcomes and colon cancer is no exception in this case. Oncology specialists recommend certain screening tests for healthy people even with no signs and symptoms in order to look for signs of colon cancer or non-cancerous colon polyps. Regular and standard screening tests help to detect the condition in its earliest stages and provide the greatest chance of cure. Screening tests like – colonoscopy, CT colonography (virtual colonoscopy), sigmoidoscopy, fecal immunochemical test (FIT) and stool DNA test will help detect the disease in its early stages. The American Cancer Society (ACS) recommends regular screenings starting at the age of 45 and the Centers for Disease Control and Prevention (CDC) recommends screening at 50 years.

Medicare covers colorectal screening services for beneficiaries aged 50 and older. If the patient is at an average risk for colorectal cancer, the interval is every 10 years. If the patient is at high risk for colorectal cancer, the frequency may be more often. Patients at high risk for colon cancer generally have one or more of the following characteristics –

  • Close family member (sister, brother, parent, child) who has had colorectal cancer or an adenomatous polyp
  • Family history of adenomatous polyposis or hereditary non-polyposis colorectal cancer
  • Personal history of adenomatous polyps, colorectal cancer or inflammatory bowel disease (Crohn’s disease or ulcerative colitis)

HCPCS Codes for Reporting Colon Cancer Screening Services

In most cases, HCPCS Level II codes are used to report colon cancer screening services for Medicare patients.

  • G0121 – Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

    (This code is billed for patients who are receiving a routine colon cancer screening and are not at high risk for developing the condition. Medicare covers this service once every 10 years. At least 47 months must have passed following the month in which the patient received a covered screening flexible sigmoidoscopy. Code G0121 and diagnosis code Z12.11 Encounter for screening for malignant neoplasm of colon are appropriate for a routine screening colonoscopy with no abnormal findings).

  • G0105 – Colorectal cancer screening; colonoscopy on individual at high risk

    (For patients identified as high risk for developing colon cancer, this service may be covered once every two years. These high-risk individuals may receive their first screening at a younger age, to be determined by their physician. )

  • G0104 – Colorectal cancer screening; flexible sigmoidoscopy

    This screening service may be covered once every 48 months unless the beneficiary meets the criteria for high risk of developing colorectal cancer and the patient has had a screening colonoscopy within the preceding 10 years. Code G0104 may be covered only after at least 120 months have passed since the last screening colonoscopy (G0121).

Screening Turned Diagnostic Rules

During a screening colonoscopy, if the healthcare provider finds a polyp or something, bill the appropriate diagnostic CPT code rather than the screening service code. Payers may vary in diagnosis coding requirements in this scenario. In most cases, it is important to report the screening diagnosis code followed by the diagnostic code. Be sure to check the payer’s policy before billing. Medicare (and most payers) requires you to append modifier PT (a colorectal cancer screening test which led to a diagnostic procedure to the procedure code) as this allows them to charge the appropriate coinsurance and deductible amounts.

ICD-10 Diagnosis Codes for Colon Cancer (specific to the location of the cancer)

  • C18 Malignant neoplasm of colon
  • C18.0 Malignant neoplasm of cecum
  • C18.1 Malignant neoplasm of appendix
  • C18.2 Malignant neoplasm of ascending colon
  • C18.3 Malignant neoplasm of hepatic flexure
  • C18.4 Malignant neoplasm of transverse colon
  • C18.5 Malignant neoplasm of splenic flexure
  • C18.6 Malignant neoplasm of descending colon
  • C18.7 Malignant neoplasm of sigmoid colon
  • C18.8 Malignant neoplasm of overlapping sites of colon
  • C18.9 Malignant neoplasm of colon, unspecified
  • C19 Malignant neoplasm of rectosigmoid junction
  • C20 Malignant neoplasm of rectum
  • C21 Malignant neoplasm of anus and anal canal
  • C21.0 Malignant neoplasm of anus, unspecified
  • C21.1 Malignant neoplasm of anal canal
  • C21.2 Malignant neoplasm of cloacogenic zone
  • C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal

Alternative Screening Test

People with Medicare who don’t show symptoms of colorectal cancer will have access to the Cologuard™ – a home screening test that detects certain DNA markers and blood in the test-taker’s stool. This way, physicians can find these polyps and you can get them removed before they turn into cancer. Found to detect 92 percent of colon cancers and 42 percent of high-risk pre-cancers, most payers cover Cologuard™ under a preventive care benefit. Patients should discuss results with their healthcare provider to determine when they should be re-screened or if further testing is necessary.

CPT Codes for Colorectal Cancer

  • 00811 Anesthesia for lower intestinal endoscopic procedures, endoscopy introduced distal to duodenum; not otherwise specified
  • 00812 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy
  • 74263 Computed tomographic (CT) colonography, screening, including image post processing (Non-Covered)
  • 81528 Oncology (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 result
  • 82270 Blood, occult, by peroxidase activity (e.g., guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (i.e., patient was provided 3 cards or single triple card for consecutive collection)

Healthcare providers need to remain updated about the specific medical codes and the related screening guidelines to report colorectal cancer correctly. Paying close attention to coding guidelines and payer policies when billing any procedure or service is crucial as this will give you the knowledge to code with accuracy. Relying on medical billing services offered by AAPC-certified billers and coders can help physicians optimize reimbursement for the services they offer.