CMS Colorectal Cancer Screening Policy Update (NCD 281): What Billing Teams Need to Know for 2026

The Centers for Medicare & Medicaid Services has modified NCD 281, its National Coverage Determination governing colorectal cancer screening tests, with an updated effective date of March 12, 2026. This policy governs Medicare Part B coverage for a range of screening modalities—from traditional fecal occult blood tests to multi-target stool DNA testing and CT colonography—and the changes affect eligibility thresholds, frequency limits, and documentation requirements that directly impact claim submission and reimbursement.

CMS Medicare Coverage for Colorectal Cancer Screening Tests: What NCD 281 Covers

Medicare Part B coverage for colorectal cancer screening is authorized under Sections 1861(s)(2)(R) and 1861(pp) of the Social Security Act, along with regulations at 42 CFR 410.37. These provisions grant CMS authority to add or modify covered tests and procedures as appropriate, following consultation with relevant clinical organizations. NCD 281 defines exactly which screening modalities Medicare will reimburse, for which patient populations, and at what frequency.

Understanding this policy isn't optional for billing teams—these are hard coverage rules. Claims submitted outside the defined frequency intervals or for patients who don't meet the age criteria will deny, and those denials are difficult to overturn because the service simply isn't covered under those conditions.

Fecal Occult Blood Test (FOBT) Coverage: Age, Frequency, and Documentation Requirements

Medicare covers one screening FOBT per year for the early detection of colorectal cancer. Coverage applies to both guaiac fecal occult blood tests (gFOBT) and immunoassay fecal occult blood tests (iFOBT). The frequency rule is specific: at least 11 months must have passed following the month in which the last covered screening FOBT was performed.

Key age threshold (updated January 1, 2023): The minimum age for FOBT coverage is now 45 years and older. This is a significant change from the prior threshold of 50 years, and any billing team that hasn't already updated its eligibility screening workflows should do so immediately ahead of the 2026 policy version taking effect.

Documentation requirement: FOBT screening requires a written order from the beneficiary's attending physician. CMS defines "attending physician" as a doctor of medicine or osteopathy who is fully knowledgeable about the beneficiary's medical condition and would be responsible for using the results in the overall management of the beneficiary's specific medical problem. Verbal orders or standing protocol orders that don't meet this definition create documentation risk.

How the tests are performed:

• gFOBT: The beneficiary takes samples from two different sites of three consecutive stools.
• iFOBT: The beneficiary collects the number of stool samples specified by the manufacturer's instructions.

Cologuard™ Multi-Target Stool DNA (sDNA) Test: CMS Coverage Rules

The Cologuard™ multi-target stool DNA test has been covered under Medicare since October 9, 2014. This proprietary in vitro diagnostic device combines sDNA and fecal immunochemical test (FIT) techniques to analyze stool samples for molecular markers associated with colorectal cancer and pre-malignant colorectal neoplasia.

The test works by detecting DNA markers shed by colorectal cancer cells and pre-malignant epithelial neoplasia into the large bowel lumen. Using selective enrichment and amplification techniques, it is designed to identify very small quantities of these markers.

Coverage frequency: Once every three years for eligible Medicare beneficiaries.

Billing teams should note that the three-year interval is a hard CMS coverage rule—not a clinical recommendation. Claims submitted before the interval has elapsed will deny as not covered, regardless of clinical rationale. Confirming the date of the last covered sDNA test before submitting a new claim is a basic but frequently missed step.

CT Colonography and Other Covered Screening Modalities Under NCD 281

NCD 281 covers a broader set of colorectal cancer screening modalities beyond FOBT and sDNA testing. The full policy summary provided in the CMS source document outlines coverage criteria for additional test types. Billing teams should review the complete policy at the CMS source document to confirm current coverage status for all modalities used within their practice.

Each modality carries its own frequency rule, age requirement, and documentation standard. Running a single blanket workflow across all colorectal screening types is one of the most common billing errors in this category.

Prior Authorization Requirements Under NCD 281

The policy as summarized does not describe a prior authorization requirement for covered colorectal cancer screening tests under Medicare Part B. However, billing teams should verify that local Medicare Administrative Contractor (MAC) policies don't impose additional requirements in their jurisdiction, as LCD-level rules can layer on top of NCDs.

Affected Codes

This policy does not list specific CPT or HCPCS codes within the data provided for NCD 281-v7. CMS publishes NCD 281 as a coverage framework, with associated billing codes typically mapped through the Medicare Claims Processing Manual and MAC-level guidance.

What your billing team should do: Cross-reference NCD 281 with your MAC's LCD and billing articles to confirm the exact HCPCS and CPT codes applicable in your region. Common codes historically associated with colorectal cancer screening include codes in the HCPCS G-code series for colonoscopy and stool-based tests, but do not assume prior code sets remain valid under the updated 2026 policy version without MAC confirmation.

What Your Billing Team Should Do