Medicare Coverage for Colonoscopy Screenings

Original Medicare covers colorectal cancer screening using MT-sDNA and blood-based biomarker tests for members with Part B who meets these criteria:

Aged 45-85 years
Asymptomatic
At average colorectal cancer risk

It also covers screening colonoscopies, fecal occult blood tests (FOBTs) flexible sigmoidoscopies, and barium enemas for members with Part B who meets at least one of these criteria:

No minimum age requirement for screening colonoscopies
Aged 45 and older at normal colorectal cancer risk
At high risk for colorectal cancer which means an individual with below conditions:
1. A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;
2. A family history of familial adenomatous polyposis;
3. A family history of hereditary nonpolyposis colorectal cancer;
4. A personal history of adenomatous polyps; or
5. A personal history of colorectal cancer; or
6. Inflammatory bowel disease, including Crohn’s Disease, and ulcerative colitis.

Effective January 1, 2023, if the patient initially has a non-invasive stool-based screening test (FOBT or MT-sDNA test) and gets a positive result, Medicare also covers a follow-up colonoscopy as a screening test. The patient pays nothing for the screening test if their doctor or other qualified health care provider accepts assignment. The frequency limitations described for screening colonoscopies in Tables 1 and 2 do not apply in this scenario.

The frequency of Medicare coverage for colonoscopy screenings is as follows:

**Table 1. Patients Not Meeting High-Risk Criteria**
Service	Timeframe
MT-sDNA and blood-based biomarker tests	Once every 3 years
Screening FOBT	Once every 12 months
Screening flexible sigmoidoscopy	Once every 48 months (unless the patient doesn’t meet high-risk colorectal cancer criteria and had a screening colonoscopy within the preceding 10 years. If so, we may cover a screening flexible sigmoidoscopy only after at least 119 months passed following the month the patient got the screening colonoscopy).
Screening colonoscopy	Once every 120 months (10 years) or 48 months after a previous sigmoidoscopy
Screening barium enema (when used instead of a flexible sigmoidoscopy or colonoscopy)	Once every 48 months

**Table 2. High-Risk Patients**
Service	Timeframe
Screening FOBT	Once every 12 months
Screening flexible sigmoidoscopy	Once every 48 months
Screening colonoscopy	Once every 24 months (unless patient got a screening flexible sigmoidoscopy and then we may cover a screening colonoscopy only after at least 47 months)
Screening barium enema (when used instead of a flexible sigmoidoscopy or colonoscopy)	Once every 24 months

Medicare Advantage plans cover colorectal cancer screening at 100% for in-network providers. Effective 1/1/2023, MA will waive cost sharing and deductible when a screening colorectal cancer procedure becomes a diagnostic or therapeutic service.

Coding guidelines

When a scheduled screening colorectal cancer procedure turned into a diagnostic or therapeutic service (for example, removal of polyps during the screening procedure); append modifier PT to at least one of the diagnostic or therapeutic service codes for the listed procedures to be covered at 100%.

FROM scheduled screening colorectal cancer procedure	TO a diagnostic or therapeutic service	Billing instruction	MA plan covers
G0104, G0105 or G0121	10000 – 69999	Append PT modifier to at least one of the codes in column B	100% for all codes in column B
	G0500
	00811
	99153

References

CURRENT AS OF 08/03/2026

Revision History

Date	Nature of Revision
08/03/2026	Migrated to new platform.