CMS Pub. 100-04, ch. 18, § 60.1

Payment is under the MPFS except as follows:

• FOBTs [CPT 82270* (HCPCS G0107*) and HCPCS G0328] are paid under the CLFS except

reasonable cost is paid to all non-outpatient prospective payment system (OPPS) hospitals,

including Critical Access Hospitals (CAHs), but not Indian Health Service (IHS) hospitals

billing on type of bill (TOB) 83X. IHS hospitals billing on TOB 83X are paid the Ambulatory

Surgery Center (ASC) payment amount. Other IHS hospitals (billing on TOB 13X) are paid

the Office of Management and Budget (OMB)-approved all-inclusive rate (AIR), or the facility

specific per visit amount as applicable. Deductible and coinsurance do not apply for these tests.

See section A below for payment to Maryland waiver hospitals on TOB 13X. Payment to all

hospitals for non-patient laboratory specimens on TOB 14X will be based on the CLFS,

including CAHs and Maryland waiver hospitals.

• For claims with dates of service on or after January 1, 2015, through December 31, 2015, the

Cologuard™ multi-target sDNA test (HCPCS G0464) is paid under the CLFS.

Note: For claims with dates of service October 9, 2014, thru December 31, 2014, HCPCS code

G0464 is paid under local contractor pricing.

• For claims with dates of service on or after January 1, 2016, CPT code 81528 replaces G0464 is

paid under the CLFS.

• For claims with dates of service on or after January 19, 2021, Blood-based Biomarker test

(HCPCS G0327) is paid under the CLFS

• Flexible sigmoidoscopy (code G0104) is paid under OPPS for hospital outpatient departments

and on a reasonable cost basis for CAHs; or current payment methodologies for hospitals not

subject to OPPS.

• Colonoscopies (HCPCS G0105 and G0121) and barium enemas (HCPCS G0106 and

G0120) are paid under OPPS for hospital outpatient departments and on a reasonable cost

basis for CAHs or current payment methodologies for hospitals not subject to OPPS. Also

colonoscopies may be performed in an ASC and when done in an ASC, the ASC rate

applies. The ASC rate is the same for diagnostic and screening colonoscopies. The ASC

rate is paid to IHS hospitals when the service is billed on TOB 83X.

The following screening codes must be paid at rates consistent with the rates of the diagnostic

codes indicated. Coinsurance and deductible apply to diagnostic codes.

HCPCS Screening Code HCPCS Diagnostic Code

G0104 45330

G0105 and G0121 45378

G0106 and G0120 74280

A. Special Payment Instructions for TOB 13X Maryland Waiver Hospitals

For hospitals in Maryland under the jurisdiction of the Health Services Cost Review Commission,

screening colorectal services HCPCS G0104, G0105, G0106, 82270* (G0107*), G0120, G0121,

G0328, G0464, and 81528 are paid according to the terms of the waiver, that is 94% of submitted

charges minus any unmet existing deductible, co-insurance and non-covered charges. Maryland

Hospitals bill TOB 13X for outpatient colorectal cancer screenings.

B. Special Payment Instructions for Non-Patient Laboratory Specimen (TOB 14X) for All

Hospitals

Payment for colorectal cancer screenings (CPT 82270* (HCPCS G0107*), HCPCS G0328, and

G0464 (Effective January 1, 2016, HCPCS G0464 is discontinued and replaced with CPT 81528)

to a hospital for a non-patient laboratory specimen (TOB 14X), is the lesser of the actual charge,

the fee schedule amount, or the National Limitation Amount (NLA), (including CAHs and

Maryland Waiver hospitals). Part B deductible and coinsurance do not apply.

• *NOTE: For claims with dates of service prior to January 1, 2007, physicians, suppliers,

and providers report HCPCS G0107. Effective January 1, 2007, HCPCS G0107 was

discontinued and replaced with CPT 82270.