BCCHP Allowable Reimbursement Schedule
Colorectal Cancer Screening and Diagnosis
July 1, 2012 – June 30, 2013
CPT®
HCPCS
Modifier
EVALUATION AND MANAGEMENT PROCEDURES
Professional
Professional
Procedure Code Description
Non-Facility
Facility
OFFICE
PROVIDER
99201
Global
New patient-problem focused, straightforward 10 min
$
46.37
99202
Global
New patient expanded focused, straightforward 20 min
$
78.55
99203
Global
New patient detailed-low complexity 30 min
$
113.32
99204
Global
Office-new patient moderate complexity 45 min
$
171.89
99205
Global
Office-new patient high complexity 60 min
$
212.93
99211
Global
Established patient-problem focused, straightforward 5 min
$
21.77
99212
Global
Established patient- expanded focused, straightforward 10 min
$
43.82
99213
Global
Established patient-expanded focused, low complexity 15 min
$
76.05
CPT®
HCPCS
Modifier
PREVENTIVE MEDICINE PROCEDURES
Professional
Professional
Procedure Code Description
Non-Facility
Facility
OFFICE
PROVIDER
99386
Global
Preventive visit, new patient, 40-64
$
113.32
99387
Global
Preventive visit new patient, 65+
$
113.32
99396
Global
Preventive visit, established patient, 40-64
$
76.05
99397
Global
Preventive visit, established patient, 65+
$
76.05
CPT®
HCPCS
Modifier
00810
Global
00840
Global
Ambulatory
Surgery
Center
Lab
Hospital
Outpatient
Ambulatory
Surgery
Center
Lab
1
ANESTHESIA PROCEDURES
Professional
Procedure Code Description
Non-Facility
OFFICE
Anesthesia intraperitoneal procedure lower abdomen ($250 max)
[(Base Unit (5) + Time Unit) x Conversion Factor (CF) = Fee
Anesthesia lower intestinal endoscopy lower abdomen ($250 max)
[(Base Unit (5) + Time Unit) x Conversion Factor (CF) = Fee
Hospital
Outpatient
Professional
Facility
PROVIDER
$
22.16 CF
$
22.16 CF
Hospital
Outpatient
Ambulatory
Surgery
Center
Lab
Hospital
Outpatient
Ambulatory
Surgery
Center
Lab
MISCELLANEOUS PROCEDURES
CPT®
HCPCS
BCCOV
Modifier
-
Professional
Non-Facility
OFFICE
Procedure Code Description
Office Visit Add-On (Handling of FOBTs)
$
Professional
Facility
PROVIDER
15.00
For persons with disabilities, this document is available on request in other formats. To submit a request, call 1-800-525-0127, (TDD/TTY 711).
DOH 432-030 June 2012
BCCHP Allowable Reimbursement Schedule
Colorectal Cancer Screening and Diagnosis
July 1, 2012 – June 30, 2013
CPT®
HCPCS
Modifier
G0104
45330
45331
Global
Global
Global
45333
45334
45335
Global
Global
Global
45338
45339
G0121
G0105
45378
45380
45381
45382
45383
Global
Global
Global
Global
Global
Global
Global
Global
Global
45384
Global
45385
74270
74270TC
7427026
Global
Global
TC
26
74280
Global
74280TC
TC
7428026
26
COLORECTAL CANCER SCREENING AND DIAGNOSTIC PROCEDURES
Professional
Professional
Procedure Code Description
Non-Facility
Facility
OFFICE
PROVIDER
Screening Sigmoidoscopy
Diagnostic Flexible Sigmoidoscopy (Base)
Sigmoidoscopy-biopsy(ies) (add-on)
Sigmoidoscopy-removal of tumors, polyps or lesions, hot biopsy
forceps or bipolar cautery (add-on)
Sigmoidoscopy-control of bleeding (add-on)
Sigmoidoscopy-submucosal injection(s) (add-on)
Sigmoidoscopy-removal of tumor(s), polyp(s) or lesion(s) by snare
technique (add-on)
Sigmoidoscopy-ablation of tumor(s), polyp(s) or lesion(s) (add-on)
Screening Colonoscopy-average risk individual
Screening Colonoscopy-increased risk individual
Diagnostic Colonoscopy (Base)
Colonoscopy-biopsy(ies) (add-on)
Colonoscopy-submucosal injection(s) (add-on)
Colonoscopy-control of bleeding (add-on)
Colonoscopy-ablation of tumor(s), polyp(s) or lesion(s) (add-on)
Colonoscopy- removal of tumors, polyps or lesions, hot biopsy
forceps or bipolar cautery (add-on)
Colonoscopy- removal of tumor(s), polyp(s) or lesion(s) by snare
technique (add-on)
X-ray exam, colon-contrast (e.g. Barium) with or without KUB
X-ray exam, colon-contrast (e.g. Barium) with or without KUB
X-ray exam, colon-contrast (e.g. Barium) with or without KUB
X-ray exam, colon-air contrast-High-Density Barium, with or without
glucagon
X-ray exam, colon-air contrast-High-Density Barium, with or without
glucagon
X-ray exam, colon-air contrast-High-Density Barium, with or without
glucagon
Hospital
Outpatient
Ambulatory
Surgery
Center
$
$
$
158.40
158.40
189.59
$
$
$
68.45
68.45
82.12
$
$
$
378.30
435.79
435.79
$
$
$
106.74
106.74
254.34
$
$
$
337.88
175.86
308.99
$
$
$
118.26
175.86
99.50
$
$
$
435.79
774.78
435.79
$
$
$
254.34
452.19
254.34
$
$
$
$
$
$
$
$
$
363.15
380.94
440.42
440.42
440.42
525.88
525.65
687.41
630.47
$
$
$
$
$
$
$
$
$
151.71
199.49
232.10
232.10
232.10
277.84
499.37
353.80
340.38
$
$
$
$
$
$
$
$
$
435.79
774.78
581.31
581.31
655.31
655.31
655.31
655.31
655.31
$
$
$
$
$
$
$
$
$
254.34
452.19
339.28
339.28
382.47
382.47
382.47
382.47
382.47
$
520.00
$
289.10
$
655.31
$
382.47
$
$
$
$
590.11
145.77
98.04
35.40
$
$
$
$
329.22
145.77
98.04
35.40
$
$
655.31
85.83
$
$
$
382.47
$
232.12
$
232.12
$
$
162.68
$
162.68
$
83.00
$
50.45
$
50.45
For persons with disabilities, this document is available on request in other formats. To submit a request, call 1-800-525-0127, (TDD/TTY 711).
50.09
142.21
DOH 432-030 June 2012
Lab
2
BCCHP Allowable Reimbursement Schedule
Colorectal Cancer Screening and Diagnosis
July 1, 2012 – June 30, 2013
COLORECTAL CANCER SCREENING AND DIAGNOSTIC PROCEDURES
CPT
HCPCS
Modifier
Professional
Non-Facility
OFFICE
Procedure Code Description
Professional
Facility
PROVIDER
Hospital
Outpatient
Ambulatory
Surgery
Center
Lab
82270
Global
gFOBT Guiac Fecal Occult Blood Test
$
4.61
82274
cprep
Global
--
iFOBT Immunochemical Fecal Occult Blood Test)
Colon Preparation Kit-maximum $100 (Pay actual amount)
$
$
22.53
100.00
stamp
--
Stamped envelope (for mailing gFOBT/iFOBT)
$
1.46
88300
Global
Surgical pathology-gross examination(I)
$
31.82
$
31.82
88300TC
TC
Surgical pathology-gross examination (I)
$
27.17
$
27.17
8830026
26
Surgical pathology-gross examination (I)
$
4.65
$
4.65
Global
Surgical pathology-gross and microscopic examination (II)
$
63.15
$
63.15
88302TC
TC
Surgical pathology-gross and microscopic examination (II)
$
56.37
$
56.37
8830226
26
Surgical pathology-gross and microscopic examination (II)
$
6.78
$
6.78
Global
Surgical pathology-gross and microscopic examination (III)
$
69.80
$
69.80
88304TC
TC
Surgical pathology-gross and microscopic examination (III)
$
58.32
$
58.32
8830426
26
Surgical pathology-gross and microscopic examination (III)
$
11.48
$
11.48
Global
Surgical pathology-gross and microscopic examination (IV)
$
117.88
$
117.88
88305TC
TC
Surgical pathology-gross and microscopic examination (IV)
$
79.74
$
79.74
8830526
26
Surgical pathology-gross and microscopic examination (IV)
$
38.15
$
38.15
Global
Surgical pathology-gross and microscopic examination (V)
$
261.40
$
261.40
88307TC
TC
Surgical pathology-gross and microscopic examination (V)
$
177.86
$
177.86
8830726
26
Surgical pathology-gross and microscopic examination (V)
$
83.54
$
83.54
Global
Surgical pathology-gross and microscopic examination (VI)
$
394.20
$
394.20
TC
Surgical pathology-gross and microscopic examination (VI)
$
247.38
$
247.38
26
Global
TC
Surgical pathology-gross and microscopic examination (VI)
Immunohistochemistry, each antibody
Immunohistochemistry, each antibody
$
$
$
146.81
116.91
73.89
$
$
$
146.81
116.91
73.89
Immunohistochemistry, each antibody
$
43.02
$
43.02
88302
88304
88305
88307
88309
88309TC
8830926
88342
88342TC
8834226
26
For persons with disabilities, this document is available on request in other formats. To submit a request, call 1-800-525-0127, (TDD/TTY 711).
$
11.16
$
17.08
$
36.81
3
$
36.81
$
57.66
$
57.66
$
36.81
DOH 432-030 June 2012
BCCHP Allowable Reimbursement Schedule
Colorectal Cancer Screening and Diagnosis
July 1, 2012 – June 30, 2013
END NOTES
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
Use the Healthcare Common Procedure Codes (HCPCS) or Current Procedural Terminology® (CPT®) codes and modifiers. Providers must bill using these descriptions. Reimbursement for all
procedures follows Medicare rules. Procedures cannot be reimbursed for more than Medicare allows. Washington state BCCHP uses Locality Code 2 calculations based on King County rates.
The type and duration of office visits should be appropriate to the level of care necessary for accomplishing screening and diagnostic follow-up within the BCCHP and reimbursement rates will
not exceed those published by Medicare. Codes 99386, 99387 will be reimbursed at the 99203 code rate following CDCs program requirements.
Consultations should be billed through Evaluation and Management (E/M) codes. Consultations must meet the criteria for the code. Type and duration of E/M visits should be appropriate to the
level of care needed for performing screening and diagnostic follow-up.
Anesthesia services are reimbursed using Medicare's methodology. [(Base Unit + Time Unit) x Conversion Factor = Fee]. The program does not reimburse for propofol. The program has
established a $250.00 maximum reimbursement fee. Payment above the maximum fee may be considered with sufficient justification.
Codes 88143, 88174 and 88175 will be reimbursed at the 88142 rate based on CDC requirements.
Treatment of pre-cancerous and invasive colorectal cancer is not reimbursable. This includes surgery or surgical-staging unless required to provide a histological diagnosis of cancer.
Some procedures are bundled which means reimbursement is associated with another procedure. Procedures performed in a hospital outpatient or ambulatory surgery center settings are
usually bundled.
Endoscopy procedures (sigmoidoscopy and colonoscopy) are based on “family” codes. Provider fees will be paid following the Medicare endoscopy rules: when two endoscopies in the same
family are performed, the endoscopy with the highest fee schedule amount will be paid at 100%. Additional related endoscopies are priced by subtracting the base endoscopy price. The
amount of the base procedure code will be paid. Professional facility provider fees for additional codes in the family will be reimbursed as add-on procedures for additional codes. Payment for
the base procedure is included in the payment for the most expensive endoscopy. Facility fees will be paid as follows: The endoscopy with the highest fee schedule will be paid at 100%.
Additional related endoscopies will be paid at 50% the highest price endoscopy in the “family” code.
Reimbursement for pre-operative, intra-operative, post-operative, routine follow-up care is bundled into the procedure code. This also includes any complications resulting from the procedure.
This is different than an Evaluation and Management (E/M) visit. E/M visits are not payable for pre-operative care or post-operative follow-up. An E/M visit may be separately payable if the
service is for the underlying condition related to the screening results. An appropriate diagnosis code must be documented. Code 36415 may only be billed once per encounter for the
collection of single or multiple specimens by the facility performing the procedure. Billing for specific laboratory or diagnostic tests should be done by the facility performing the laboratory test.
Endoscopy codes G0104, G0121 or G0105 should be used for screening. Code 45330 (and family codes) and Code 45378 (and family codes) should be used if screening becomes a
diagnostic procedure.
Code BCCOV is a code developed by the BCCHP. It is provided for distribution and handling of FOBTs in addition to the CPT code fee. CPT 82770 and 82274 will be paid to the CLIAwaivered clinic or the CLIA certified laboratory when the FOBT is tested.
Colorectal Cancer Screening will be reimbursed following the US Preventive Services Task Force (USPSTF) Screening Guidelines and program eligibility criteria.
CT colonography (virtual colonoscopy) is not reimbursable
Care or services for medical complications resulting from screening or diagnostic tests are not reimbursable by the program
Genetic testing is not reimbursable by the program.
Screening or care for other conditions (including gastrointestinal conditions e.g. inflammatory bowel disease) is not reimbursable by the program.
References:
 Current Procedural Terminology® (CPT®) 2011 – American Medical Association (AMA)
 Healthcare Common Procedure Coding System (HCPCS) 2011, Centers for Medicare and Medicaid Services (CMS)
 Noridian Administrative Services: https://www.noridianmedicare.com/p-medb/%3f
 Centers for Medicare and Medicaid Services (CMS): http://www.cms.gov/
For persons with disabilities, this document is available on request in other formats. To submit a request, call 1-800-525-0127, (TDD/TTY 711).
DOH 432-030 June 2012
4