Coverage of MT-sDNA Test (Cologuard®) for Colorectal Screening
The South Carolina Department of Health and Human Services (SCDHHS) will add the multi-targeted stool DNA (MT-sDNA) test, also known as Cologuard®, in the covered preventive screenings beginning July 1, 2023. This change aligns with the United States Preventive Services Task Force (USPSTF) recommendation for colorectal screening. This coverage applies to full-benefitHealthy Connections Medicaid members and those enrolled in the Family Planning limited benefit program.
Clinical Criteria:
- The MT-sDNA test is recommended every three years for asymptomatic, low-average risk members, aged 45 to 75 years who:
- Have not had any colorectal screening in the past, or
- Have had a negative colonoscopy at least seven years prior.
- The MT-sDNA test is not recommendedfor high-risk individuals who:
- Have a personal history of colorectal cancer and adenomas;
- Have had a positive result from another colorectal cancer screening at any time; or,
- Have been diagnosed with a condition associated with high risk for colorectal cancer such as inflammatory bowel disease, chronic ulcerative colitis, or Crohn’s disease; or have a family history of colorectal cancer, or certain hereditary syndromes.
Reimbursement Rate and Code
The test should be billed by using CPT code 81528. Reimbursement for this screening for Healthy Connections Medicaid members enrolled in the fee-for-service Medicaid program will be $396.92.
Updated policy language will be available in the Physicians Services provider manual on the agency’s website by July 1, 2023.
Providers should direct any questions about this bulletin to the Provider Service Center (PSC) at (888) 289-0709. The PSC’s hours of operations are 7:30 a.m.-5 p.m. Monday-Thursday and 8:30 a.m.-5 p.m. Friday. Providers may also submit an online inquiry.
South Carolina’s Medicaid managed care organizations (MCO) are responsible for the coverage and reimbursement related to the services described in this bulletin for Healthy Connections Medicaid members who are enrolled in an MCO.
Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.