Tag: #colonoscopy

Posted in #Medicareadvantage, #reimbursement, Cinga Insurance, Payer Updates, Payers and CPT reinbursement

Aetna: Cologuard reimbursement

Posted on by KR2Medical Billing

As per Aetna for their Commercial and Medicare Plans: Cologuard test will be denied when it is performed within a year that the patient had a Colonoscopy.

Colonoscopy codes: 45378–45398 or G0121

This will be effective for any DOS on Jan 1,2025 and thereafter.

What is Cologuard?

According to the Cologuard website: the non-invasive at home colon cancer screening test that is available for patients 45 and older who have an average risk of colon cancer.

What is an average risk?

Patients that do not have a history of colon cancer in their family or personal history, as well as IBD.

Please note that there is no specific insurance information that is available on the Cologuard website. Cologuard might not be covered at all with your insurance. Please double check if it going to be covered before doing it.

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Posted in HEDIS Measures, Training, Updates

HEDIS Measure: Colorectal Cancer Screening (COL)

Posted on by KR2Medical Billing

This HEDIS® measure evaluates the percentage of patients age 50 to 75 who had appropriate screening for colorectal cancer.

In order for PCPs to get credit for this Measure they need to document the following:

Document (date and result) one or more of these screenings:

  • Colonoscopy during measurement year or nine years prior
  • Fecal occult blood test (FOBT) during measurement year
  • CT colonography during measurement year or four years prior
  • Fecal immunochemical test (FIT)-DNA test during measurement year or two years prior
  • Flexible sigmoidoscopy during measurement year or four years prior

There following are exclusions for this measure:

  • Diagnosis of colorectal cancer
  • Total colectomy
  • Members who receive palliative 

Quest Test available:

There is an option for your patient to get a FIT kits through Quest Diagnostics.®* This option is only available for PARTICIPATING providers.

Quest will ship InSure® ONE™ FIT kits directly to your practice. There are 2 ways to order:

  • Online, use the Quest Quanum® Lab Services Manager. Create an account at https://bit.ly/3qLxNPh.
  • Via phone, call 1-866-MY-QUEST and state supplies for assistance.

Quest will ship the kits to your practice at no cost, based on usage and test completion.