CMS Pub. 100-04, ch. 18, § 60.7

The following Medicare Summary Notice (MSN) messages are used (See Chapter 21 for the

Spanish versions of these messages):

A. If a claim for a screening FOBT, a screening flexible sigmoidoscopy, or a barium enema is

being denied because of the age of the beneficiary, use:

18.29 - This service is not covered for people under 45 years of age.

Spanish Version- “Este servicio no está cubierto para las personas menores de 45 años.”

B. If the claim for a screening FOBT, a screening colonoscopy, a screening flexible

sigmoidoscopy, or a barium enema is being denied because the time period between the same

test or procedure has not passed, use:

18.14 - Service is being denied because it has not been (12, 24, 48, 120) months since your

last (test/procedure) of this kind.

C. If the claim is being denied for a screening colonoscopy or a barium enema because the

beneficiary is not at a high risk, use:

18.15 - Medicare covers this procedure only for people considered to be at a high risk

for colorectal cancer.

D. If the claim is being denied because payment has already been made for a screening FOBT

(CPT 82270* (HCPCS G0107*) or HCPCS G0328), flexible sigmoidoscopy (HCPCS G0104),

screening colonoscopy (HCPCS G0105), or a screening barium enema (HCPCS G0106 or

G0120), use:

18.16 - This service is denied because payment has already been made for a similar

procedure within a set timeframe.

NOTE: MSN message 18.16 should only be used when a certain screening procedure is

performed as an alternative to another screening procedure. For example: If the claims history

indicates a payment has been made for HCPCS G0120 and an incoming claim is submitted for

HCPCS G0105 within 24 months, the incoming claim should be denied.

E. If the claim is being denied for a non-covered screening procedure code such as HCPCS

G0122, use:

16.10 - Medicare does not pay for this item or service.

If an invalid procedure code is reported, the contractor will return the claim as unprocessable to

the provider under current procedures.

*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 is discontinued and

replaced with CPT 82270.

F. If denying claims for Cologuard™ multi-target sDNA screening test (HCPCS G0464 -

Effective January 1, 2016, HCPCS G0464 has been discontinued and replaced with CPT 81528)

or Blood-based Biomarker test (HCPCS G0327) when furnished more than once in a 3-year

period [at least 2 years and 11 full months (35 months total) must elapse from the date of the last

screening], use:

15.19: “We used a Local Coverage Determination (LCD) to decide coverage for your claim. To

appeal, get a copy of the LCD at www.cms.gov/medicare-coverage-database (use the MSN

Billing Code for the CPT/HCPCS Code) and send with information from your doctor."

Spanish Version - Usamos una Determinación de Cobertura Local (LCD) para decidir la

cobertura de su reclamo. Para apelar, obtenga una copia del LCD en www.cms.gov/medicare-coverage-database (use el código de facturación de MSN para el código "CPT/HCPCS") y

envíela con la información de su médico.

15.20 - The following policies NCD 210.3 were used when we made this decision

Spanish Version – “Las siguientes políticas NCD210.3 fueron utilizadas cuando se tomó esta

decisión”

NOTE: Due to system requirement, the Fiscal Intermediary Standard System (FISS) has

combined messages 15.19 and 15.20 so that, when used for the same line item, both messages

will appear on the same MSN.

G. If denying claims for Cologuard™ multi-target sDNA screening test (HCPCS G0464 -

Effective January 1, 2016, HCPCS G0464 has been discontinued and replaced with CPT 81528)

or Blood-based Biomarker test (HCPCS G0327) because the beneficiary is not between the ages

of 45 and 85, use:

15.19 - “We used a Local Coverage Determination (LCD) to decide coverage for your claim. To

appeal, get a copy of the LCD at www.cms.gov/medicare-coverage-database (use the MSN

Billing Code for the CPT/HCPCS Code) and send with information from your doctor."

Spanish Version - Usamos una Determinación de Cobertura Local (LCD) para decidir la

cobertura de su reclamo. Para apelar, obtenga una copia del LCD en www.cms.gov/medicare-coverage-database (use el código de facturación de MSN para el código "CPT/HCPCS") y

envíela con la información de su médico.

15.20 - The following policies NCD 210.3 were used when we made this decision.

Spanish Version – “Las siguientes políticas NCD 210.3 fueron utilizadas cuando se tomó esta

decision.”

NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when

used for the same line item, both messages will appear on the same MSN.

H. If denying claims for Cologuard™ multi-target sDNA screening test (HCPCS G0464 -

Effective January 1, 2016, HCPCS G0464 has been discontinued and replaced with CPT 81528)

or Blood-based Biomarker test (HCPCS G0327) because the claim does not contain all of the

ICD-10 diagnosis codes required, use:

15.19 - “We used a Local Coverage Determination (LCD) to decide coverage for your claim. To

appeal, get a copy of the LCD at www.cms.gov/medicare-coverage-database (use the MSN

Billing Code for the CPT/HCPCS Code) and send with information from your doctor."

Spanish Version - Usamos una Determinación de Cobertura Local (LCD) para decidir la

cobertura de su reclamo. Para apelar, obtenga una copia del LCD en www.cms.gov/medicare-coverage-database (use el código de facturación de MSN para el código "CPT/HCPCS") y

envíela con la información de su médico.

15.20 - The following policies 210.3 were used when we made this decision

Spanish Version – “Las siguientes políticas NCD210.3 fueron utilizadas cuando se tomó esta

decisión”

NOTE: Due to system requirement, FISS has combined messages 15.19 and 15.20 so that, when

used for the same line item, both messages will appear on the same MSN.

I. If denying claims for Cologuard™ multi-target sDNA screening test (HCPCS G0464 -

Effective January 1, 2016, HCPCS G0464 has been discontinued and replaced with CPT 81528)

or Blood-based Biomarker test (HCPCS G0327) on institutional claims when submitted on a

TOB other than 13X, 14X, and 85X, use:

21.25 - This service was denied because Medicare only covers this service in certain settings.

Spanish Version: “El servicio fue denegado porque Medicare solamente lo cubre en ciertas

situaciones."