Stool DNA Testing for Colorectal Cancer Screening Code Update

Effective for dates of service on or after October 1, 2016, CPT code 81528 (oncology [colorectal] screening, quantitative real-time target and signal amplification of 10 DNA markers [KRAS mutations, promoter methylation of NDRG4 and BMP3] and fecal hemoglobin, utilizing stool, algorithm reported as a positive or negative result) is a new Medi-Cal benefit and will replace HCPCS code G0464 (colorectal cancer screening; stool-based DNA and fecal occult hemoglobin). HCPCS code G0464 is no longer a Medi-Cal benefit. Code 81528 is reimbursable for recipients 50 to 75 years of age. For recipients outside this age range, providers must submit a Treatment Authorization Request (TAR) documenting medical necessity. Colorectal cancer screening reimbursement is limited to once per year for any provider, same recipient. For recipients requiring additional tests within a year, providers must submit a TAR documenting medical necessity. An Erroneous Payment Correction (EPC) will be initiated to reprocess affected claims.