Colorectal Cancer Screening Tests — NCD 281 | CMS Coverage Update

CMS modified NCD 281 governing colorectal cancer screening coverage, effective January 9, 2026. Here's what changes for billing teams.

The Centers for Medicare & Medicaid Services updated this coverage policy under NCD 281 Medicare to reflect expanded eligibility criteria for colorectal cancer screening tests. The most significant change: the minimum age for covered screening dropped from 50 to 45 for multiple test types. No specific CPT or HCPCS codes are listed in the current policy document — but the test types, frequency rules, and eligibility criteria are detailed enough to drive real claim denial risk if your team isn't current on them.

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Quick-Reference Table

Field	Detail Copy
Payer	CMS (Centers for Medicare & Medicaid Services)
Policy	Colorectal Cancer Screening Tests
Policy Code	NCD 281
Change Type	Modified
Effective Date	January 9, 2026
Impact Level	High
Specialties Affected	Gastroenterology, Primary Care, Lab/Pathology, General Surgery
Key Action	Update eligibility screening workflows to flag patients aged 45–49 as covered for colorectal cancer screening under Medicare

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CMS Colorectal Cancer Screening Coverage Criteria and Medical Necessity Requirements 2026

NCD 281 is the National Coverage Determination governing Medicare coverage of colorectal cancer screening tests under Medicare Part B. Authority comes from Sections 1861(s)(2)(R) and 1861(pp) of the Social Security Act, along with 42 CFR 410.37.

The real issue here for billing teams is the age floor. The coverage policy now allows Medicare-covered colorectal cancer screening starting at age 45 — not 50. That's not a minor administrative tweak. It opens a meaningful population of beneficiaries who were previously uncovered for these tests, and it changes how you should be building eligibility checks.

Here's how each covered test type breaks down.

Fecal Occult Blood Tests (FOBT)

Medicare covers one FOBT per year. "Per year" means at least 11 months have passed since the month of the last covered FOBT. Mark that carefully — it's not a calendar-year reset.

Two types are covered: guaiac FOBT (gFOBT) and immunoassay FOBT (iFOBT). Both require a written order from the beneficiary's attending physician. The policy defines "attending physician" specifically: a doctor of medicine or osteopathy under §1861(r)(1) of the Act who is fully knowledgeable about the patient's condition and responsible for using the results in ongoing management. Nurse practitioners writing orders here is a medical necessity documentation risk. Flag that for your providers.

The age change for FOBT is effective January 1, 2023 — so this isn't new to the 2026 update, but NCD 281 v7 consolidates it. If your team has been billing FOBT for 45–49-year-olds under Medicare and denials have been a problem, this policy version is your documentation anchor.

Cologuard™ — Multi-Target Stool DNA (sDNA) Test

Medicare covers the Cologuard™ multi-target sDNA test once every three years. Coverage became effective October 9, 2014, and the test remains covered under this updated policy.

The Cologuard™ test combines sDNA analysis and fecal immunochemical test (FIT) techniques. It detects molecular markers of altered DNA shed by colorectal cancer cells and pre-malignant colorectal epithelial neoplasia. For billing purposes, this is an in vitro diagnostic device — not a procedure code — and how your lab handles the claim matters for reimbursement.

Three-year frequency is strict. If a patient had Cologuard™ less than three years ago under Medicare, a subsequent claim will likely hit a claim denial. Build that frequency check into your pre-authorization workflow now.

Prior Authorization and Ordering Requirements

The policy does not establish a formal prior authorization requirement for these screening tests. But the written physician order requirement for FOBT is a hard documentation rule — not optional. Missing or incomplete orders are a denial waiting to happen.

For sDNA testing, work with your lab partners to confirm the order documentation is in place before the specimen is collected. A verbal order reconstructed after the fact won't hold up under a medical necessity review.

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CMS Colorectal Cancer Screening Exclusions and Non-Covered Indications

The policy is mostly permissive — it's designed to expand coverage, not restrict it. But there are meaningful boundaries.

Coverage is specifically for screening. If a patient presents with symptoms — rectal bleeding, change in bowel habits, documented family history triggering diagnostic (not screening) evaluation — the clinical and billing context shifts entirely. A diagnostic colonoscopy is not a screening colonoscopy. Your coders need to be making this distinction on every claim.

Patients under age 45 are not covered for Medicare colorectal cancer screening under NCD 281. Age 45 is the floor, and there's no exception language for high-risk patients under that threshold under this coverage policy.

Tests performed outside the authorized frequency windows — more than once per year for FOBT, more than once every three years for Cologuard™ — are not covered. Frequency-based denials are preventable. They're almost always a workflow failure, not a clinical one.

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Coverage Indications at a Glance

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CMS Colorectal Cancer Screening Billing Guidelines and Action Items 2026

Copy Action Items

If your practice has a high volume of Medicare patients in the 45–54 age range, talk to your compliance officer before January 9, 2026 about how this policy change interacts with your existing screening protocols and billing workflows.

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CPT, HCPCS, and ICD-10 Codes for Colorectal Cancer Screening Under NCD 281

The current version of NCD 281 (policy key 281-v7, effective January 9, 2026) does not list specific CPT or HCPCS codes within the policy document. This is not unusual for NCDs — the applicable procedure codes are typically mapped at the MAC level or through the Medicare Claims Processing Manual rather than inside the NCD itself.

What This Means for Your Colorectal Cancer Screening Billing

You'll need to cross-reference with your regional Medicare Administrative Contractor for the current mapped codes. Historically, colorectal cancer screening billing has used HCPCS codes in the G-code range for screening colonoscopy and FOBT, and a specific HCPCS code for the Cologuard™ sDNA test — but verify the current active codes with your MAC rather than relying on codes from prior years.

This is a gap worth flagging to your billing consultant. NCD 281 sets the coverage rules; the MAC-level local coverage determination and billing instructions tell you exactly which codes to submit. The two documents work together.

Do not submit claims using codes you haven't verified against current MAC guidance. A mismatch between the NCD coverage criteria and the code you submit is one of the cleaner paths to a claim denial.

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