Provider Alert! Colorectal Cancer Screening Benefit Criteria to Change for Texas Medicaid

Attention: PCPs and Oncologists

Effective Date: March 1, 2021

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Effective for dates of service on or after March 1, 2021, colorectal cancer screening benefit criteria will change for Texas Medicaid. Fecal occult blood tests, multi-targeted stool deoxyribonucleic acid (mt-sDNA) tests, screening colonoscopies, and sigmoidoscopies are evidence-based methods of colorectal cancer screening. Procedure codes G0106, G0120, and G0122 will no longer be reimbursed for colorectal cancer screenings.

How this impacts providers: Tests, procedure codes, and limitations are as follows:
Fecal Occult Blood Tests- Procedure codes G0328 (with modifier QW) and 82270 may be reimbursed one service per rolling year for clients who are 45 years of age and older.

MT-sDNA Test-Procedure code 81528 may be reimbursed once every 3 years for clients who are 45 years of age and older for services rendered in the laboratory setting.

Sigmoidoscopies-Procedure code G0104 may be reimbursed for clients who are 45 years of age and older.

Colonoscopies: Average Risk-Procedure code G0121 may be reimbursed once per 10 rolling years for clients who are 45 years of age and older.

Diagnosis code Z86010 (Personal history of colonic polyps) will no longer be diagnosis-restricted for procedure code G0121 for average risk colonoscopies.

Exclusions-Barium enemas for colorectal cancer screening are not a benefit of Texas Medicaid.

The American Cancer Society (ACS) recommends screening people at average risk for colorectal cancer beginning at 45 years of age by any of the following methods:

• A fecal occult blood test (FOBT) or fecal immunochemical test (FIT) every year
• A mt-sDNA every 3 years
• A flexible sigmoidoscopy every 5 years
• A flexible sigmoidoscopy every 10 years in addition to annual FIT screening
• A colonoscopy every 10 years

The U.S. Preventive Services Task Force (USPSTF) guidelines indicate that the net benefit of colorectal cancer screening in adults who are 76 years of age and older who have been previously screened is small. The risks should be considered on an individual basis, as screening in this age group is most appropriate for those healthy enough to undergo treatment.

The ACS and USPSTF recommends screening for people who are at high risk for colorectal cancer once every 2 years.

Source: TMHP Notice dated 1/15/2021

Next steps for providers: Providers should share this communication with their staff.

If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.
For access to all provider alerts, log into:
www.thecheckup.org or www.texaschildrenshealthplan.org/for-providers.