Does G0105 require prior authorization?

No, G0105 does not require prior authorization (high confidence). Covered without prior authorization.

What is the Medicare reimbursement rate for G0105?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 3.18.

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`G0105`, Colorectal cancer screening; colonoscopy on individual at high risk

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

3.18

Facility

N/A

Non-Facility

N/A

Documentation Required

Select the CPT code that accurately describes the diagnostic/therapeutic procedure that was performed or attempted during the colonoscopy.
Append the -PT modifier to the selected CPT code to indicate a screening colonoscopy was converted to a diagnostic or therapeutic procedure.

Use an appropriate ICD-10 diagnosis code indicating the procedure was a screening (example: Z80.0) when submitting the claim for a converted screening colonoscopy.

Document clinical findings in the medical record that demonstrate the screening colonoscopy was converted to diagnostic/therapeutic (e.g., description of encountered pathology and performed intervention).

Medical record must document the extenuating/unforeseen circumstances and the specific inability to advance the colonoscope to the cecum or colon–small intestine anastomosis to support billing as an incomplete procedure.

Submit the failed colonoscopy on the claim using CPT 45378, HCPCS G0105 or G0121, or CPT 44388 (stoma) with modifier -53 appended.

Key Coverage Criteria

If a screening colonoscopy encounters pathology that necessitates intervention converting it to a diagnostic or therapeutic colonoscopy, bill using the appropriate diagnostic/therapeutic CPT code appended with the -PT modifier and an appropriate screening ICD-10 diagnosis.
When beneficiaries are at high risk for colorectal malignancy, an ICD-10 screening code such as Z80.0 (family history of malignant neoplasm of digestive organs) may be used to indicate the procedure was a screening converted to diagnostic/therapeutic.
A colonoscopy attempt that cannot be completed because of extenuating/unforeseen circumstances (e.g., inability to advance the colonoscope to the cecum or to a colon–small intestine anastomosis) is considered an incomplete/failed colonoscopy.
Policy applies to both screening and diagnostic colonoscopies.
Colonoscopy/sigmoidoscopy/proctosigmoidoscopy is covered for surveillance of colonic neoplasia in patients with a history of colorectal cancer or colonic polyps.
A follow-up procedure is covered 1 year after surgery for treatment of colorectal cancer when the patient is identified as high-risk for colon cancer and is eligible for continued screenings.

11 Active Policies

PALMETTO-JJ-L34454, Colonoscopy /Sigmoidoscopy /Proctosigmoidoscopy

PALMETTO-JM-L34454, Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

A55227, Billing and Coding: Incomplete Colonoscopy/Failed Colonoscopy

A56632, Billing and Coding: Colonoscopy/Sigmoidoscopy/Proctosigmoidoscopy

UHC-POL-screening-colonoscopy-procedures-site-service, Screening Colonoscopy Procedures – Site of Service

AETNA-CPB-0783, In Vivo Analysis of Gastro-Intestinal and Urothelial Lesions

CIGNA-A004, Preventive Care Services

REGENCE-UM20, Site of Care - Colonoscopy and Sigmoidoscopy

ANTHEM-CG-SURG-01, Colonoscopy

UMR-POL-UMR-screening-colonoscopy-procedures-site-service, Screening Colonoscopy Procedures – Site of Service

A55069, Billing and Coding: Screening Colonoscopy Converted to a Diagnostic and/or Therapeutic Colonoscopy

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G0105, Colorectal cancer screening; colonoscopy on individual at high risk