CMS lowers CRC screening coverage age, requires new modifier for follow-up colonoscopy
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CMS has announced expanded coverage for specific colorectal cancer screening tests by lowering the minimum age to include individuals aged 45 years and older under Medicare Part B.
“CMS is expanding coverage for colonoscopy for all Americans at age 45 instead of age 50. This is a welcome change, as it aligns with evidence-based guidelines by the United States Preventive Services Taskforce,” Shazia Siddique, MD, MSHP, assistant professor of medicine at the University of Pennsylvania and director of research at the Center for Healthcare Improvement and Patient Safety, told Healio. “Thanks to the Affordable Care Act, screening colonoscopies are essentially free for Americans, and now this is extended to Americans between ages 45 to 49 as well.”
According to the report, CMS will now allow coverage for the following CRC screening tests:
- flexible sigmoidoscopy (Healthcare Common Procedure Coding System (HCPCS) code G0104);
- guaiac-based fecal occult blood test (CPT 82270);
- immunoassay-based fecal occult blood test (HCPCS G0328);
- Cologuard multi-target stool DNA test (CPT 81528);
- barium enema test (HCPCS codes G0106 [when administered as screening sigmoidoscopy alternative] and G0120 [when administered as screening colonoscopy alternative]); and
- blood-based biomarker test (HCPCS code G0327).
“The second change is that patients who are screened for colon cancer with a stool-based test, and test positive, can now get a follow-up colonoscopy that is also ‘free’ [as it is] covered by Medicare,” Siddique said. “This is because CMS is allowing this follow-up colonoscopy to be billed as a screening colonoscopy, rather than as a diagnostic colonoscopy, which typically incurs additional costs.”
Providers must apply modifier KX to unlock policy adjustments that have been implemented as of February 27, 2023, in time for Colorectal Cancer Awareness Month. AGA has noted that failure to attach the KX modifier will produce a screening colonoscopy claim as “unprocessable” through Medicare.
“Our policy goal of not having frequency limitations to the follow-on screening colonoscopy, after a non-invasive stool-based test returns a positive result, is to remove barriers and encourage the patient to proceed to the colonoscopy procedure soon after the positive result from the stool-based test,” noted CMS members.
Siddique added: “As providers, we provide evidence-based care, which is recommending colonoscopy to screen for colon cancer for patients 45 and older and recommending colonoscopy for those who have a positive screening stool test. The new CMS policies are crucial to eliminating the real-life financial barriers that patients face when they try to follow our recommendations. Now, patients can proceed with these evidence-based, life-saving practices with the knowledge that these services will be covered by CMS.”
References:
American Academy of American Physicians. CMS lowers age to start covering most CRC screening tests. https://www.aafp.org/news/practice-professional-issues/cms-crc-screening-coverage.html. Accessed: Feb. 28, 2023.
American Gastroenterological Association. Medicare requires new modifier for CRC follow-up colonoscopy claims. https://gastro.org/news/medicare-requires-new-modifier-for-crc-follow-on-colonoscopy-claims/. Accessed: Feb. 28, 2023.
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