Billing FECAL-OCCULT BLOOD TEST-G0328

FECAL-OCCULT BLOOD TEST-G0328 

Medicare will cover a new colorectal cancer screening for fecal-occult blood test, HCPCS G0328 effective for dates of service on/after January 1, 2004. This article provides coverage, coding, frequency and billing guidelines for this service.

Policy

Medicare will cover the new colorectal cancer screening FOBT G0328 beginning January 1, 2004. G0328 is payable under the clinical lab fee schedule. Medicare patients aged 50 and over can only receive one FOBT per year, either G0107 (gFOBT, or guaiac-based) or G0328 (iFOBT, or immunoassay-based).

A covered screening FOBT is allowed once every 12 months for beneficiaries who have attained age 50 (i.e., at least 11 months have passed following the month in which the last covered screening FOBT was performed). Medicare will allow either one covered G0107 gFOBT or one covered G0328 iFOBT, but not both during a 12-month period.

Screening FOBT means: (1) a guaiac-based test for peroxidase activity in which the beneficiary completes it by taking samples from two different sites of three consecutive stools or, (2) a immunoassay (or immunochemical) test for antibody activity in which the beneficiary completes the test by taking the appropriate number of samples according to the specific manufacturer?s instructions.

This expanded coverage is in accordance with revised regulations at 42 CFR 410.37(a)(2) that includes "other tests determined by the Secretary through a national coverage determination." This screening requires a written order from the beneficiary?s attending physician. (The term "attending physician" is defined to mean a doctor of medicine or osteopathy who is fully knowledgeable about the beneficiary?s medical condition and who would be responsible for using the results of any examination performed in the overall management of the beneficiary?s specific medical problem.)

This coverage revision is a National Coverage Determination (NCD). NCDs are binding on all Medicare carriers, fiscal intermediaries, quality improvement organizations, health maintenance organizations, competitive medical plans and health care prepayment plans. Under 42 CFR 422.256(b), an NCD that expands coverage is also binding on a Medicare Choice Organization. In addition, an administrative law judge may not review an NCD (See Section 1869(f)(1)(A)(i) of the Social Security Act).


Applies to the state of AK, AZ, CO, HI, IA, ND, NV, OR, SD, WA & WY.