Issue 2006-04, April 2006

Colorectal Cancer: Preventable, Treatable, and Beatable: Medicare Coverage and Billing for Colorectal Cancer Screening

Provider Types Affected
Physicians, nurse practitioners, physician assistants, clinical nurse specialists, outpatient hospital departments, community surgical centers

Provider Action Needed

Impact to You
April is National Colorectal Cancer Awareness Month. The Centers for Medicare & Medicaid Services (CMS) would like to remind providers to encourage their eligible Medicare patients ages 50 and older to get screened for colorectal cancer. This Medlearn Matters Special Edition issue reviews Medicare coverage and billing processes for colorectal cancer screening.

What You Need to Do
Encourage your patients to be screened, appropriately bill Medicare for the screening test you provide, and follow up with patients, as needed.

Background
Colorectal cancer is the second leading cause of cancer death in the United States and the third most common type of cancer. In 2005, colorectal cancer was expected to account for 56,290 deaths and 145,290 new cases. Colorectal cancer primarily affects men and women ages 50 and older, and risk increases with age.

If detected early, colorectal cancer can be treated and cured.

Medlearn Matters Number: SE0613 Related Change Request Number: N/A
In January 1998, Medicare began covering colorectal cancer screening. The data currently available (1998 - 2002) indicates that the colorectal cancer screening benefit is underused. Less than half of enrollees had any colorectal cancer test during the five-year period and less than one-third were tested according to recommended intervals.

The U.S. Preventive Services Task Force (USPSTF) evaluates the clinical merits of preventive measures, and strongly recommends (“A” rating) that clinicians screen men and women ages 50 and older for colorectal cancer. The choice of screening strategy should be based on patient preferences, medical contraindications, patient adherence, and resources for testing and follow-up. To read the full recommendation, go to the following link: http://www.ahrq.gov/clinic/uspstf/uspscolo.htm.

The Partnership for Prevention conducted a systematic assessment of the clinical preventive services recommended by the USPSTF to help decision-makers identify those services that provide the most value based on two criteria—burden of disease prevented and cost-effectiveness. Screening adults for colorectal cancer screening was among the services considered to be of the greatest value.

Colorectal Cancer Screening Methods
There are a variety of methods available for colorectal cancer screening, including fecal occult blood testing, flexible sigmoidoscopy, colonoscopy, and screening barium enema. It is important that practitioners follow the practice guidelines for screening and follow-up.

Two studies published in January 2005 in the Annals of Internal Medicine suggest that the office-based single sample screening fecal occult blood test is of limited value, and that many physicians are not following practice guidelines for screening and follow-up. Click on the following link for information on colorectal cancer detection and American Cancer Society screening recommendations and guidelines: http://www.cancer.org/docroot/CRI/content/CRI_2_6X_Colorectal_Cancer_Early_Detection_10.asp?sitearea=&level.

Coverage
Medicare covers the following colorectal cancer screening tests and procedures:

Fecal Occult Blood Test (FOBT)
Medicare covers one FOBT annually for beneficiaries 50 and older. A written order from the beneficiary’s attending physician is required. Medicare will pay for an immunoassay-based FOBT as an alternative to the guaiac-based FOBT, but will only pay for one FOBT, not both, per year.

Beneficiaries do not have to pay coinsurance for the FOBT, and don’t have to meet the annual Medicare Part B deductible.

Screening Flexible Sigmoidoscopy
Medicare covers a screening flexible sigmoidoscopy once every four years for beneficiaries 50 and older. If a beneficiary had a screening colonoscopy in the previous ten years, then the next screening flexible sigmoidoscopy would be covered only after 119 months have passed following the month in which the last screening colonoscopy was performed. A doctor of medicine or osteopathy, a physician assistant, a nurse practitioner, or a clinical nurse specialist may perform a screening flexible sigmoidoscopy.

Screening Colonoscopy
Medicare coverage for a screening colonoscopy is based on beneficiary risk.

• For beneficiaries 50 and older not considered to be at high risk for developing colorectal cancer, Medicare covers one screening colonoscopy every 10 years, but not within 47 months of a previous screening flexible sigmoidoscopy.
• For beneficiaries considered to be at high risk for developing colorectal cancer, Medicare covers one screening colonoscopy every two years, regardless of age.

A screening colonoscopy must be ordered and provided by a doctor of medicine or osteopathy.

Screening Barium Enema
Medicare covers a screening barium enema as an alternative to a screening flexible sigmoidoscopy or a screening colon oscopy.

• For beneficiaries 50 and older not considered to be at high risk for developing colorectal cancer, Medicare covers one screening barium enema every four years.
• For beneficiaries considered to be at high risk for developing colorectal cancer, Medicare covers one screening barium enema every two years regardless of age.

A screening barium enema must be ordered in writing and provided by a doctor of medicine or osteopathy once it is determined that it is the appropriate screening method for a beneficiary. A double contrast barium enema is preferable, but the physician may order a single contrast barium enema if it is more appropriate for the beneficiary.

The beneficiary is liable for paying 20 percent of the Medicare-approved amount (the coinsurance) for screening flexible sigmoidoscopy, screening colonoscopy, and screening barium enema after meeting the annual Medicare Part B deductible.

For a screening flexible sigmoidoscopy or a screening colonoscopy performed in a hospital outpatient department, the beneficiary is liable for paying the Medicare-approved amount (the coinsurance) after meeting the annual Medicare Part B deductible.

Beneficiaries are considered to be at high risk for colorectal cancer if they have any of the following:

• A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;
• A family history of adenomatous polyposis;
• A family history of hereditary nonpolyposis colorectal cancer;
• A personal history of adenomatous polyps;
• A personal history of colorectal cancer;
• A personal history of inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis.

How to Bill Medicare

The following Healthcare Common Procedure Coding System (HCPCS) codes should be used to bill for colorectal cancer screening:

If billing Medicare carriers, the appropriate HCPCS and corresponding diagnosis codes must be provided on Form CMS-1500 (or the HIPAA 837 Professional electronic claim record).

If billing Medicare intermediaries, the appropriate HCPCS, revenue, and corresponding diagnosis codes must be provided on Form CMS-1450 (or the HIPAA Institutional electronic claim record). Information on the type of bill and associated revenue code is also provided in the colorectal cancer screening chapter (page 82) of the Guide to Preventive Services. This guide is available at: http://www.cms.hhs.gov/ MedlearnProducts/downloads/PSGUID.pdf on the CMS Web site. Reimbursement information is also provided in this guide.

Other Helpful Information

CMS has developed a comprehensive prevention Web site that provides information and resources for all Medicare preventive benefits. The following link is to the colorectal cancer screening section, and includes Web site links to information and resources developed by other organizations interested in promoting colorectal cancer screening, including the National Cancer Institute, the Centers for Disease Control and Prevention, and the American Cancer Society: http://www.cms.hhs.gov/ ColorectalCancerScreening/.

Also, visit the Medicare Learning Network (MLN) Web site at http://www.cms.hhs.gov/Medlearn/ to access the Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care Professionals as well as other educational resources designed for health care professionals to promote and increase national awareness of Medicare-covered preventive services. Once on the MLN site, scroll to the bottom of the page and click on Products, then click on Preventive Services.

Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.

For more information, visit the Medlearn Matters Web page at: http://www.cms.hhs.gov/ MedlearnMattersArticles.

Medlearn Matters Number: SE0613
Related Change Request (CR) #: N/A
Related CR Release Date: N/A
Effective Date: N/A