Coverage Policy Manual
Policy #: 2011045
Category: PPACA Preventive
Initiated: September 2010
Last Review: January 2024
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: COLORECTAL CANCER SCREENING
Description:
The Federal Patient Protection and Preventive Care Act was passed by Congress and signed into law by the President in March 2010.  The preventive services component of the law became effective 23 September 2010.  A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force.  
 
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
 
Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention.  Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds.  Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.  Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
 
Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, co-insurance, or co-pay).by Health Plans for appropriate preventive care services provided by an in-network provider.  If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, co-insurance, or copay may be applied.
 
Coding
In 2018, CPT released a new code 00812 specific for screening colonoscopy.
 
CPT 00812 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy
 
Prior to 2018, this service would have been reported with CPT 00810. CPT 00810 was deleted 12/31/2017.
 
If sedation is used for a screening colonoscopy, we would expect that CPT 00812 be used to report this service. Modifier -33 will not be required when reporting CPT 00812 because the service reported by CPT 00812 is inherently preventive.
Policy/
Coverage:
In accordance with Act 779 [Colorectal Cancer Screening] of the Arkansas legislature for all contracts subject to this law: a) coverage of colorectal cancer screening is provided at no cost-share for covered persons aged 45 years or older and b) extended coverage of colorectal cancer screening is provided at no cost-share when covered person meets criteria for high risk.
 
For contracts subject to Arkansas Act 779, a colonoscopy that is performed as a follow-up to a colorectal cancer screening test, other than a colonoscopy, will be covered at no cost-share when the initial screening test resulted in a positive and the initial screening test is assigned a grade of “A” or a grade of “B” by the United States Preventive Services Task Force.
 
Colonoscopy remains the preferred testing method for individuals at average and high risk of colorectal cancer including those with a family history of colorectal cancer, individuals with a previous screening that was positive for adenomatous or precancerous polyps, or for those otherwise acknowledged as high risk for colorectal cancer [including but not limited to a personal history of colorectal cancer, a personal history of inflammatory bowel disease such as Crohn’s disease or ulcerative colitis, or a personal diagnosis of a genetic condition causing an increased risk of colorectal cancer].
 
EFFECTIVE JANUARY 1, 2024
 
Screening for colorectal cancer using the following techniques is covered for all adults aged 45 to 75 years without cost sharing (i.e., deductible, co-insurance, or co-pay).
 
    • Fecal immunochemical test [FIT] (annually) or guaiac fecal occult blood test (gFOBT) (annually)
    • CT colonography (every 5 years)
    • Sigmoidoscopy (every 5 years OR every 10 years when combined with annual FIT)
    • Colonoscopy (every 10 years)
    • Stool DNA FIT test (i.e., Cologuard) (every 3 years) (This test is intended for testing individuals at average risk for colorectal cancer, it is not covered for individuals at high risk of colorectal cancer.)
 
Stool-based screening (i.e., FIT, gFOBT) and Stool DNA FIT testing (i.e., Cologuard) performed as a screening test for colorectal cancer will not be allowed in any situation other than those described above. Stool DNA FIT testing (i.e., Cologuard) is not covered for diagnostic testing.
 
If non-stool-based screening (e.g., CT colonography, Sigmoidoscopy, Colonoscopy) for colorectal cancer has been performed, stool-based screening (i.e., FIT, gFOBT) and/or stool DNA testing (i.e., Cologuard) will not be allowed in the same year in any situation other than those described above. If a stool-based screening or stool DNA screening has been done, an additional stool-based screening or stool DNA test will not be allowed in the same year.
 
A follow-up colonoscopy to evaluate abnormal results found on a stool-based colorectal screening test or following flexible sigmoidoscopy or CT colonography is covered. The colonoscopy will be covered without cost share (i.e., deductible, co-insurance, or co-pay) for adults aged 45 - 75 years who have not received a colonoscopy in the last 10 years (e.g., colonoscopy is recommended by the USPSTF for colorectal cancer screening every 10 years for asymptomatic adults aged 45-75).
 
Note: A follow-up colonoscopy to evaluate abnormal results found on a stool-based colorectal screening test or following flexible sigmoidoscopy or CT colonography rendered more frequently than every 10 years is covered but will be subject to deductible, co-insurance, and co-pay.
 
The appropriate ICD-10 codes to report these screening services are Z12.11 or Z12.12.
 
Codes that may be used to report the procedures are G0104, G0105, G0121, G0328, 74263, 81528, 82270, or 82274.
 
HCPCS code G0500 should be billed for the first 15 minutes of sedation, if moderate (conscious) sedation is performed in conjunction with GI procedures (HCPCS G0104, G0105, G0121). If additional time is needed, CPT 99153 should be used for each additional 15 minutes.
 
CPT 00812 may also be billed in association with G0104, G0105 and G0121.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.
 
The correct coding as listed for both ICD-10 and CPT or HCPCS codes are also required.
 
It is possible that a screening study is converted to a diagnostic study or an intervention. When a screening study is converted to a diagnostic or interventional procedure no cost sharing will be applied. Codes that may be used to report these procedures include 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45346, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45388, 88305 and 00812. When these services are billed for a screening study converted to a diagnostic study or intervention they may be billed with Modifier ‘-33’ or Modifier ‘-PT’ – colorectal cancer screening test; converted to diagnostic test or other procedure.
 
Additionally, the related code CPT 88305 may be billed with this service and should be billed using Modifier ‘-33’. Modifier ‘-PT’ is not valid with this code.
 
EFFECTIVE JANUARY 2023 – DECEMBER 2023
 
Screening for colorectal cancer using the following techniques is covered for all adults aged 45 to 75 years without cost sharing (i.e., deductible, co-insurance, or co-pay).
 
    • Fecal immunochemical test [FIT] (annually) or guaiac fecal occult blood test (gFOBT) (annually)
    • CT colonography (every 5 years)
    • Sigmoidoscopy (every 5 years OR every 10 years when combined with annual FIT)
    • Colonoscopy (every 10 years)
    • Stool DNA FIT test (i.e., Cologuard) (every 3 years) (This test is intended for testing individuals at average risk for colorectal cancer, it is not covered for individuals at high risk of colorectal cancer.)
 
Stool-based screening (i.e., FIT, gFOBT) and Stool DNA FIT testing (i.e., Cologuard) performed as a screening test for colorectal cancer will not be allowed in any situation other than those described above. Stool DNA FIT testing (i.e., Cologuard) is not covered for diagnostic testing.
 
If non-stool-based screening (e.g., CT colonography, Sigmoidoscopy, Colonoscopy) for colorectal cancer has been performed, stool-based screening (i.e., FIT, gFOBT) and/or stool DNA testing (i.e., Cologuard) will not be allowed in the same year in any situation other than those described above. If a stool-based screening or stool DNA screening has been done, an additional stool-based screening or stool DNA test will not be allowed in the same year.
 
 
The appropriate ICD-10 codes to report these screening services are Z12.11 or Z12.12.
 
Codes that may be used to report the procedures are G0104, G0105, G0121, G0328, 74263, 81528, 82270, or 82274.
 
HCPCS code G0500 should be billed for the first 15 minutes of sedation, if moderate (conscious) sedation is performed in conjunction with GI procedures (HCPCS G0104, G0105, G0121). If additional time is needed, CPT 99153 should be used for each additional 15 minutes.
 
CPT 00812 may also be billed in association with G0104, G0105 and G0121.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.
 
The correct coding as listed for both ICD-10 and CPT or HCPCS codes are also required.
 
It is possible that a screening study is converted to a diagnostic study or an intervention. When a screening study is converted to a diagnostic or interventional procedure no cost sharing will be applied. Codes that may be used to report these procedures include 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45346, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45388, 88305 and 00812. When these services are billed for a screening study converted to a diagnostic study or intervention they may be billed with Modifier ‘-33’ or Modifier ‘-PT’ – colorectal cancer screening test; converted to diagnostic test or other procedure.
 
Additionally, the related code CPT 88305 may be billed with this service and should be billed using Modifier ‘-33’. Modifier ‘-PT’ is not valid with this code.
 
EFFECTIVE PRIOR TO JANUARY 2023
 
In accordance with Act 779 [Colorectal Cancer Screening] of the Arkansas legislature for all contracts subject to this law: a) coverage of colorectal cancer screening is provided at no cost-share for covered persons aged 45 years or older and b) extended coverage of colorectal cancer screening is provided at no cost-share when covered person meets criteria for high risk.
 
For contracts subject to Arkansas Act 779,  the use of MT-DNA + FIT [e.g., Cologuard (81528)] testing is covered for the purpose of colorectal cancer screening in asymptomatic members 45 years old or greater with an average risk of colorectal cancer once every 3 years when no other colorectal cancer screening service (as recommended by the USPSTF) has been provided in the preceding 12 months. This coverage is effective January 1, 2022.
 
Colonoscopy remains the recommended test for those with a family history of the disease,  for those whose previous screenings have uncovered lesions or polyps, or for those otherwise acknowledged as high risk for colorectal cancer [including but not limited to a personal history of colorectal cancer, a personal history of inflammatory bowel disease such as Crohn’s disease or ulcerative colitis, a personal diagnosis of a genetic condition causing and increased risk of colorectal cancer].
 
Screening for colorectal cancer using fecal immunochemical test [FIT] (annually), CT colonography (every 5 years), sigmoidoscopy (every 10 years combined with annual FIT), or colonoscopy (every 10 years) is covered, beginning at age 50 years and continuing until age 75 years, for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-10 codes to report these screening services are Z12.11 or Z12.12.
 
Codes that may be used to report the procedures are G0104, G0105, G0121, G0328, 82270, or 82274.
 
HCPCS code G0500 should be billed for the first 15 minutes of sedation, if moderate (conscious) sedation is performed in conjunction with GI procedures (HCPCS G0104, G0105, G0121). If additional time is needed, CPT 99153 should be used for each additional 15 minutes.
 
CPT 00812 may also be billed in association with G0104, G0105 and G0121.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.
 
The correct coding as listed for both ICD-10 and CPT or HCPCS codes are also required.
 
It is possible that a screening study is converted to a diagnostic study or an intervention. When a screening study is converted to a diagnostic or interventional procedure no cost sharing will be applied. Codes that may be used to report these procedures include 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45346, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45388, 88305 and 00812. When these services are billed for a screening study converted to a diagnostic study or intervention they may be billed with Modifier ‘-33’ or Modifier ‘-PT’ – colorectal cancer screening test; converted to diagnostic test or other procedure.
 
Additionally, the related code CPT 88305 may be billed with this service and should be billed using Modifier ‘-33’. Modifier ‘-PT’ is not valid with this code.
 
EFFECTIVE PRIOR TO JANUARY 2019
 
Screening for colorectal cancer using fecal occult blood testing (annually), sigmoidoscopy (every 5 years combined with high-sensitivity fecal occult blood testing every 3 years), or colonoscopy (every 10 years) is covered, beginning at age 50 years and continuing until age 75 years, for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-9 codes to report these screening services are V76.41 or V76.51.
 
The appropriate ICD-10 codes to report these screening services are Z12.11 or Z12.12.
 
Codes that may be used to report the procedures are G0104, G0105, G0121, G0328, 82270, or 82274.
 
HCPCS code G0500 should be billed for the first 15 minutes of sedation, if moderate (conscious) sedation is performed in conjunction with GI procedures (HCPCS G0104, G0105, G0121). If additional time is needed, CPT 99153 should be used for each additional 15 minutes.
 
CPT 00812 may also be billed in association with G0104, G0105 and G0121.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.
 
The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
It is possible that a screening study is converted to a diagnostic study or an intervention. When a screening study is converted to a diagnostic or interventional procedure no cost sharing will be applied. Codes that may be used to report these procedures include 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45346, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45388, 88305 and 00812. When these services are billed for a screening study converted to a diagnostic study or intervention they may be billed with Modifier ‘-33’ or Modifier ‘-PT’ – colorectal cancer
screening test; converted to diagnostic test or other procedure.
 
Additionally, the related code CPT 88305 may be billed with this service and should be billed using Modifier ‘-33’. Modifier ‘-PT’ is not valid with this code.
 
EFFECTIVE SEPTEMBER 2017- DECEMBER 2017
 
Screening for colorectal cancer using fecal occult blood testing (annually), sigmoidoscopy (every 5 years combined with high-sensitivity fecal occult blood testing every 3 years), or colonoscopy (every 10 years) is covered, beginning at age 50 years and continuing until age 75 years, for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-9 codes to report these screening services are V76.41 or V76.51.
 
The appropriate ICD-10 codes to report these screening services are Z12.11 or Z11.12.
 
Codes that may be used to report the procedures are G0104, G0105, G0121, G0328, 82270, or 82274.
 
HCPCS code G0500 should be billed for the first 15 minutes of sedation, if moderate (conscious) sedation is performed in conjunction with GI procedures (HCPCS G0104, G0105, G0121). If additional time is needed, CPT 99153 should be used for each additional 15 minutes.
 
CPT 00810 may also be billed in association with G0104, G0105 and G0121.
 
When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.
 
The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
It is possible that a screening study is converted to a diagnostic study or an intervention. When a screening study is converted to a diagnostic or interventional procedure no cost sharing will be applied. Codes that may be used to report these procedures include G6022, G6024, 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45346, 45378, 45379, 45380, 45381, 45382, 45384, 45385, 45388, 88305 and 00810. When these services are billed for a screening study converted to a diagnostic study or intervention they may be billed with Modifier ‘-33’ or Modifier ‘-PT’ – colorectal cancer screening test; converted to diagnostic test or other procedure.
 
Additionally, the related code CPT 88305 may be billed with this service and should be billed using Modifier ‘-33’. Modifier ‘-PT’ is not valid with this code.
 
EFFECTIVE APRIL 2015 – AUGUST 2017
Screening for colorectal cancer using fecal occult blood testing (annually), sigmoidoscopy (every 5 years combined with high-sensitivity fecal occult blood testing every 3 years), or colonoscopy (every 10 years) is covered, beginning at age 50 years and continuing until age 75 years, for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-9 codes to report these screening services are V76.41 or V76.51.
 
The appropriate ICD-10 codes to report these screening services are Z12.11 or Z11.12.
 
Codes that may be used to report the procedures are G0104, G0105, G0121, G0328, 82270, or 82274. CPT 00810 may also be billed in association with G0104, G0105 and G0121. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.
 
The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
It is possible that a screening study is converted to a diagnostic study or an intervention. When a screening study is converted to a diagnostic or interventional procedure no cost sharing will be applied. Codes that may be used to report these procedures include G6022, G6024, 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45346, 45378, 45379, 45380, 45381, 45382, 45383, 45384, 45385, 45388, 88305 and 00810. When these services are billed for a screening study converted to a diagnostic study or intervention they may be billed with Modifier ‘-33’ or Modifier ‘-PT’ – colorectal cancer screening test; converted to diagnostic test or other procedure.
 
Additionally, the related code CPT 88305 may be billed with this service and should be billed using Modifier ‘-33’. Modifier ‘-PT’ is not valid with this code.
  
EFFECTIVE FEBRUARY 2015 – MARCH 2015
 
Screening for colorectal cancer using fecal occult blood testing (annually), sigmoidoscopy (every 5 years combined with high-sensitivity fecal occult blood testing every 3 years), or colonoscopy (every 10 years) is covered, beginning at age 50 years and continuing until age 75 years, for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay).
 
The appropriate ICD-9 codes to report these services are V76.41 or V76.51.
 
Codes that may be used to report the procedures are G0104, G0105, G0121, G0328, 82270, or 82274. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.
 
The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
It is possible that a screening study is converted to a diagnostic study or an intervention. When a screening study is converted to a diagnostic or interventional procedure no cost sharing will be applied. Codes that may be used to report these procedures include G6022, G6024, 45330, 45331, 45332, 45333, 45334, 45335, 45338, 45346, 45378, 45379, 45380, 45381, 45382, 45384, 45385 and/or 45388. These services should be billed with Modifier ‘-PT’ – colorectal cancer screening test; converted to diagnostic test or other procedure.
 
Other related codes are 00810 and 88305. Modifier PT is not valid with these two codes.
 
EFFECTIVE PRIOR TO FEBRUARY 2015
 
Screening for colorectal cancer using fecal occult blood testing (annually), sigmoidoscopy (every 5 years combined with high-sensitivity fecal occult blood testing every 3 years), or colonoscopy (every 10 years) is covered, beginning at age 50 years and continuing until age 75 years,  for members of “non-grandfathered” plans, without cost sharing (i.e., deductible, co-insurance, or co-pay).  
 
The appropriate ICD-9 codes to report these services are V76.41 or V76.51.
 
Codes that may be used to report the procedures are G0104, G0105, G0121, G0328, 82270, or 82274. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.  
 
The correct coding as listed for both ICD-9 and CPT or HCPCS codes are also required.
 
It is possible that a screening study is converted to a diagnostic study or an intervention. When a screening study is converted to a diagnostic or interventional procedure no cost sharing will be applied. Codes that may be used to report theses procedures include 45330, 45331, 45333, 45338, 45339, 45378, 45380, 45381, 45383, 45384, and/or 45385.  These services should be billed with Modifier ‘-PT’ – colorectal cancer screening test; converted to diagnostic test or other procedure.  Other related codes are 00810 and 88305.  Modifier PT is not valid with these two codes.  
Rationale:
Colorectal cancer is the third most common type of cancer and the second leading cause of cancer death in the United States.
 
These recommendations apply to adults 50 years of age and older, excluding those with specific inherited syndromes (the Lynch syndrome or familial adenomatous polyposis) and those with inflammatory bowel disease. The recommendations do apply to those with first-degree relatives who have had colorectal adenomas or cancer, although for those with first-degree relatives who developed cancer at a younger age or those with multiple affected first-degree relatives, an earlier start to screening may be reasonable. The recommendations are intended to apply to all ethnic and racial groups.
 
When the screening test results in the diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable.
 
Other USPSTF conclusions about other considerations of screening for colorectal cancer:
    • For adults age 76 to 85 years, there is moderate certainty that the net benefits of screening are small;
    • For adults older than age 85 years, there is moderate certainty that the benefits of screening do not outweigh the harms;
    • FIT-DNA with annual testing is not among the model-recommendable strategies because the efficiency ratio was larger than that of the benchmark colonoscopy strategy.
 
2023 Update
Colorectal cancer is the third leading cause of cancer death for both men and women, with an estimated 52,980 persons in the US projected to die of colorectal cancer in 2021 (Siegel, 2021). Colorectal cancer is most frequently diagnosed among persons aged 65 to 74 years (NCI, 2021). It is estimated that 10.5% of new colorectal cancer cases occur in persons younger than 50 years (Siegel, 2017). Incidence of colorectal cancer (specifically adenocarcinoma) in adults aged 40 to 49 years has increased by almost 15% from 2000-2002 to 2014-2016 (Montminy, 2021). In 2016, 25.6% of eligible adults in the US had never been screened for colorectal cancer and in 2018, 31.2% were not up to date with screening (CDC, 2016, Joseph, 2018).
 
This final recommendation replaces the 2016 USPSTF recommendation on screening for colorectal cancer. In 2016, the USPSTF recommended screening for colorectal cancer starting at age 50 years and continuing until age 75 years (A recommendation). In addition, the USPSTF concluded that the decision to screen for colorectal cancer in adults aged 76 to 85 years should be an individual one, taking into account the patient’s overall health and prior screening history (C recommendation) and that screening should be discontinued after age 85 years.
 
In the current recommendation, while continuing to recommend colorectal cancer screening in adults aged 50 to 75 years (A recommendation), the USPSTF now recommends offering screening starting at age 45 years (B recommendation) (USPSTF, 2021). As it did in 2016, the USPSTF continues to conclude that screening in adults aged 76 to 85 years should be an individual decision (C recommendation) and screening should be discontinued after age 85 years.
 
High- Sensitivity gFOBT (every year)
Evidence of Efficacy:
    • Evidence from RCTs that gFOBT reduces colorectal cancer mortality
    • High-sensitivity versions (eg, Hemoccult SENSA) have superior test performance characteristics than older tests (eg, Hemoccult II), although there is still uncertainty about the precision of test sensitivity estimates. Given this uncertainty, it is unclear whether high-sensitivity gFOBT can detect as many cases of advanced adenomas and colorectal cancer as other stool-based tests
Other Considerations:
    • Harms from screening with gFOBT arise from colonoscopy to follow up abnormal gFOBT results
    • Requires dietary restrictions and three stool samples
    • Requires good adherence over multiple rounds of testing
    • Does not require bowel preparation, anesthesia, or transportation to and from the screening examination (test is performed at home)
 
FIT (every year)
Evidence of Efficacy:
    • Evidence from 1 large cohort study that screening with FIT reduces colorectal cancer mortality
    • Certain types of FIT have improved accuracy compared with gFOBT and HSgFOBT (20 μg hemoglobin per gram of feces threshold was used in the CISNET modeling)
Other Considerations:
    • Harms from screening with FIT arise from colonoscopy to follow up abnormal FIT results
    • Can be done with a single stool sample
    • Requires good adherence over multiple rounds of testing
    • Does not require bowel preparation, anesthesia or sedation, or transportation to and from the screening examination (test is performed at home)
 
sDNA-FIT (Every 1 to 3 years)
Evidence of Efficacy:
    • Improved sensitivity compared with FIT per 1-time application of screening test
    • Specificity is lower than that of FIT, resulting in more false-positive results, more follow-up colonoscopies, and more associated adverse events per sDNA-FIT screening test compared with per FIT test
    • Modeling suggests that screening every 3 y does not provide a favorable (ie, efficient) balance of benefits and harms compared with other stool-based screening options (ie, annual FIT or sDNA-FIT every 1 or 2 y)
    • Insufficient evidence about appropriate longitudinal followup of abnormal findings after a negative follow-up colonoscopy
    • No direct evidence evaluating the effect of sDNA-FIT on colorectal cancer mortality
Other Considerations:
    • Harms from screening with sDNA-FIT arise from colonoscopy to follow up abnormal sDNA-FIT results
    • Can be done with a single stool sample but involves collecting an entire bowel movement
    • Requires good adherence over multiple rounds of testing
    • Does not require bowel preparation, anesthesia or sedation, or transportation to and from the screening examination (test is performed at home)
 
Colonoscopy (every 10 years)
Evidence of Efficacy:
    • Evidence from cohort studies that colonoscopy reduces colorectal cancer mortality
    • Harms from colonoscopy include bleeding and perforation, which both increase with age
Other Considerations:
    • Screening and diagnostic follow-up of positive results can be performed during the same examination
    • Requires less frequent screening
    • Requires bowel preparation, anesthesia or sedation, and transportation to and from the screening examination
 
CT Colonography (every 5 years)
Evidence of Efficacy:
    • Evidence available that CT colonography has reasonable accuracy to detect colorectal cancer and adenomas
    • No direct evidence evaluating effect of CT colonography on colorectal cancer mortality
    • Limited evidence about the potential benefits or harms of possible evaluation and treatment of incidental extracolonic findings, which are common. Extracolonic findings detected in 1.3% to 11.4% of exams; <3% required medical or surgical treatment
Other Considerations:
    • Additional harms from screening with CT colonography arise from colonoscopy to follow up abnormal CT colonography results
    • Requires bowel preparation
    • Does not require anesthesia or transportation to and from the screening examination
 
Flexible Sigmoidoscopy (every 5 years)
Evidence of Efficacy:
    • Evidence from RCTs that flexible sigmoidoscopy reduces colorectal cancer mortality
    • Risk of bleeding and perforation but less than risk with colonoscopy
    • Modeling suggests that it provides fewer life-years gained alone than when combined with FIT or in comparison to other strategies
Other Considerations:
    • Additional harms may arise from colonoscopy to follow up abnormal flexible sigmoidoscopy results
    • Test availability has declined in the US but may be available in some communities where colonoscopy is less available
 
Flexible Sigmoidoscopy with FIT (flexible sigmoidoscopy every 10 years plus FIT every year)
Evidence of Efficacy:
    • Evidence from RCTs that flexible sigmoidoscopy + FIT reduces colorectal cancer mortality
    • Modeling suggests combination testing provides similar benefits to those of colonoscopy, with fewer complications
    • Risk of bleeding and perforation from flexible sigmoidoscopy but less than risk with colonoscopy
Other Considerations:
    • Additional potential harms from colonoscopy to follow up abnormal flexible sigmoidoscopy or FIT results
    • Flexible sigmoidoscopy availability has declined in the US but may be available in some communities where colonoscopy is less available
    • Screening with FIT requires good adherence over multiple rounds of testing
 
Summary of USPSTF Rationale (USPSTF, 2021):
Detection
Adults aged 45-49 years
    • The USPSTF found adequate evidence that screening for colorectal cancer with several different methods can accurately detect early-stage colorectal cancer and adenomatous polyps
    • Several studies on screening test accuracy include persons younger than age 50 y, although few report screening test accuracy specifically for that age group. Those studies that do generally report similar sensitivity and specificity
Adults aged 50-75 years
The USPSTF found convincing evidence that screening for colorectal cancer with several different methods can accurately detect early-stage colorectal cancer and adenomatous polyps
Adults 76 years or older
The USPSTF found convincing evidence that screening for colorectal cancer with several different methods can accurately detect early-stage colorectal cancer and adenomatous polyps
 
Benefits of early detection, intervention, and treatment
Adults aged 45-49 years
    • The USPSTF found adequate evidence that screening for colorectal cancer with stool tests, colonoscopy, CT colonography, or flexible sigmoidoscopy in adults aged 45 to 49 y provides a moderate benefit in terms of reducing colorectal cancer mortality and increasing life-years gained
    • Although no studies report on the benefits of screening specifically in adults younger than 50 y, some studies reporting an association of fewer colorectal cancer deaths with screening colonoscopy and reduced colorectal cancer mortality with screening gFOBT included patients younger than 50 y
    • Modeling analyses suggest more life-years are gained and fewer colorectal cancer deaths occur when screening begins at age 45 vs 50 y
Adults aged 50-75 years
The USPSTF found convincing evidence that screening for colorectal cancer with stool tests, colonoscopy, CT colonography, or flexible sigmoidoscopy in adults aged 50 to 75 y provides a substantial benefit in reducing colorectal cancer mortality and increasing life-years gained
Adults 76 years or older
The USPSTF found adequate evidence that routine screening for colorectal cancer with stool tests, colonoscopy, CT colonography, or flexible sigmoidoscopy in adults aged 76 to 85 y provides a small to moderate benefit in reducing colorectal cancer mortality and increasing life-years gained
 
Harms of early detection, intervention, and treatment
Adults aged 45-49 years
    • The USPSTF found adequate evidence that the harms of screening for colorectal cancer in adults aged 45 to 49 y are small. The majority of harms result from the use of colonoscopy (such as bleeding and perforation), either as the screening test or as follow-up for positive findings detected by other screening tests
    • Although fewer studies include persons younger than 50 y, overall findings suggest risk for bleeding and perforation with colonoscopy and risk for extracolonic findings with CT colonography may be lower at younger ages
Adults aged 50-75 years
The USPSTF found adequate evidence that the harms of screening for colorectal cancer in adults aged 50 to 75 y are small. The majority of harms result from the use of colonoscopy (such as bleeding and perforation), either as the screening test or as follow-up for positive findings from other screening tests
Adults 76 years or older
    • The USPSTF found adequate evidence that the harms of screening for colorectal cancer in adults 76 y and older are small to moderate. The majority of harms result from the use of colonoscopy (such as bleeding and perforation), either as the screening test or as follow-up for positive findings detected by other screening tests
    • The rate of serious adverse events from colonoscopy and the detection of extracolonic findings on CT colonography from colorectal cancer screening increase with age
 
USPSTF Assessment
Adults aged 45-49 years
The USPSTF concludes with moderate certainty that there is a moderate net benefit of starting screening for colorectal cancer in adults aged 45 to 49 y
Adults aged 50-75 years
The USPSTF concludes with high certainty that there is a substantial net benefit of screening for colorectal cancer in adults aged 50 to 75 y
Adults 76 years or older
The USPSTF concludes with moderate certainty that there is a small net benefit of screening for colorectal cancer in adults aged 76 to 85 y who have been previously screened
CPT/HCPCS:
00812Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy
45330Sigmoidoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
45331Sigmoidoscopy, flexible; with biopsy, single or multiple
45332Sigmoidoscopy, flexible; with removal of foreign body(s)
45333Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
45334Sigmoidoscopy, flexible; with control of bleeding, any method
45335Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance
45338Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45346Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre and post dilation and guide wire passage, when performed)
45378Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)
45379Colonoscopy, flexible; with removal of foreign body(s)
45380Colonoscopy, flexible; with biopsy, single or multiple
45381Colonoscopy, flexible; with directed submucosal injection(s), any substance
45382Colonoscopy, flexible; with control of bleeding, any method
45384Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps
45385Colonoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45388Colonoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) (includes pre and post dilation and guide wire passage, when performed)
74263Computed tomographic (CT) colonography, screening, including image postprocessing
81528Oncology (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
82270Blood, occult, by peroxidase activity (eg, guaiac), qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening (ie, patient was provided 3 cards or single triple card for consecutive collection)
82274Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1 3 simultaneous determinations
88305Level IV Surgical pathology, gross and microscopic examination Abortion spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curettings/biopsy Endometrium, curettings/biopsy Esophagus, biopsy Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture Fingers/toes, amputation, non traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy without uterus Lip, biopsy/wedge resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or without tube, non neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary tumor Placenta, other than third trimester Pleura/pericardium biopsy/tissue Polyp, cervical/endometrial Polyp, colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse Vagina, biopsy Vulva/labia, biopsy
99153Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; each additional 15 minutes intraservice time (List separately in addition to code for primary service)
G0104Colorectal cancer screening; flexible sigmoidoscopy
G0105Colorectal cancer screening; colonoscopy on individual at high risk
G0121Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
G0328Colorectal cancer screening; fecal occult blood test, immunoassay, 1 3 simultaneous
G0500Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intra service time; patient age 5 years or older (additional time may be reported with 99153, as appropriate)
References: Centers for Disease Control and Prevention (CDC).(2016) Quick Facts: Colorectal Cancer Screening in U.S.: Behavioral Risk Factor Surveillance System—2016. Accessed March 30, 2021. https://www.cdc.gov/cancer/colorectal/pdf/QuickFacts-BRFSS-2016-CRC-Screening-508.pdf

Joseph DA, King JB, Dowling NF, Thomas CC, Richardson LC.(2018) Vital signs: colorectal cancer screening test use—United States, 2018. MMWR Morb Mortal Wkly Rep. 2020;69(10):253-259. Medline:32163384 doi:10.15585/mmwr.mm6910a1

Montminy EM, Zhou M, Maniscalco L, et al.(2021) Contributions of adenocarcinoma and carcinoid tumors to early-onset colorectal cancer incidence rates in the United States. Ann Intern Med. 2021;174(2):157-166. Medline:33315473 doi:10.7326/M20-0068

National Cancer Institute.(2021) Cancer stat facts: colorectal cancer. Accessed March 30, 2021. https://seer.cancer.gov/statfacts/html/colorect.html

PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act

Screening for Colorectal Cancer Topic page, October, 2008. U.S. Preventive Services Task Force; http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colors.htm

Siegel RL, Miller KD, Fedewa SA, et al.(2017) Colorectal cancer statistics, 2017. CA Cancer J Clin. 2017;67(3):177-193. Medline:28248415 doi:10.3322/caac.21395

Siegel RL, Miller KD, Fuchs HE, Jemal A.(2021) Cancer statistics, 2021. CA Cancer J Clin. 2021;71(1):7-33. Medline:33433946 doi:10.3322/caac.21654

U.S. Preventive Services Task Force (USPSTF).(2021) Final Recommendation Statement Colorectal Cancer: Screening. May 18, 2021. Accessed December 12, 2022. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/colorectal-cancer-screening
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