Colorectal Cancer Screening--Provider Resources

Colorectal cancer is the second leading cause of cancer death in the U.S. Medicare has covered colorectal cancer screening since 1998, but use of this benefit has been less than optimal. Medicare claims from 1998-2004 indicate that about 52% of Medicare beneficiaries have had at least one colorectal cancer test during this period.

Health care providers have an important role to play in improving the use of this important benefit. This website provides information, resources, and tools to support clinicians in the delivery of colorectal cancer screening.

The Evidence

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. There are insufficient data to determine which screening strategy is best in terms of the balance of benefits and potential harms or cost-effectiveness. Studies reviewed by the USPSTF indicate that colorectal cancer screening is likely to be cost-effective (less than $30,000 per additional year of life gained) regardless of the strategy chosen. (See the link below to the USPSTF recommendation.)

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 2 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. (See the link below for more information on this effort.)

The Centers for Disease Control and Prevention (CDC) convenes the Task Force on Community Preventive Services, which reviews the evidence on specific health problems and summarizes what is known about effectiveness, economic efficiency and feasibility of interventions to promote community health and prevent disease in The Community Guide. According to the Task Force, there is strong evidence recommending the removal of structual barriers, such as hours of operation, and sufficient evidence to support the use of client reminders to increase colorectal cancer screening (see the link below).

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.

Medicare Coverage

Medicare covers various colorectal cancer screening methods, including the fecal occult blood test, screening flexible sigmoidoscopy, screening colonoscopy, and screening barium enema. Coverage for some of these procedures varies according to the person's risk for developing colorectal cancer. Beneficiaries are considered to be at high risk for developing colorectal cancer if they have:

• 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.

Medicare coverage for each colorectal cancer screening test or procedure is as follows:

• Fecal occult blood test (FOBT): Medicare covers 1 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 1 FOBT, not both, per year. Beneficiaries do not have to pay coinsurance or a copayment 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 4 years for beneficiaries 50 and older who are at high or low risk. If a beneficiary had a screening colonoscopy in the previous 10 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 not considered to be at high risk for developing colorectal cancer, Medicare covers 1 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 1 screening colonoscopy every 2 years, regardless of age. A screening colonoscopy must be ordered and collected 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 colonoscopy. For beneficiaries 50 and older not considered to be at high risk for developing colorectal cancer, Medicare covers 1 screening barium enema every 4 years. For beneficiaries considered to be at high risk for developing colorectal cancer, Medicare covers 1 screening barium enema every 2 years regardless of age. A screening barium enema must be ordered in writing and collected 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.

(*)As of January 1, 2007, the Medicare Part B deductible has been waived for these screening tests.  However, if the screening test results in the biopsy or removal of a lesion or growth, the procedure is considered diagnostic, and the Medicare Part B deductible applies. The beneficiary is liable for paying 25% of the Medicare-approved amount (the coinsurance or copayment) for screening tests performed in a hospital outpatient department or ambulatory surgical center.

Preventive Services Educational Products For Health Care Professionals ~ CMS has developed a variety of educational products for health care professionals to help increase awareness of preventive services covered by Medicare and provide coverage and billing information needed to effectively bill Medicare for preventive services provided to Medicare patients.

The Medicare Learning Network (MLN) is the brand name for official CMS educational products and information for Medicare fee-for-service providers. For additional information visit the Medicare Learning Network's web page.

(See Related Links Inside CMS below for link a list of available products and to the MLN web page.)

Other Helpful Information

The links below include a quick reference document, and a guide which provides detailed information on coverage and how to bill Medicare for preventive benefits, including the appropriate codes to use. Additional resources provided below include the National Cancer Institute's website information on colorectal cancer, the National Comprehensive Cancer Network's colorectal cancer patient treatment guidelines, and a link to the American Cancer Society's professionals page.

Downloads
There are no Downloads
Related Links Inside CMS
The Guide to Medicare Preventive Services for Physicians, Providers, Suppliers, and Other Health Care Professionals (page 75)[pdf,1.53MB] Modification of FISS Edits for Colorectal Cancer Screening Services Furnished at Skilled Nursing Facilities (Medlearn Matters article) [.pdf,77.3KB] Chapter 15, Medicare Benefit Policy Manual (section 280.2) [.pdf, 1.09KB] Chapter 6, Medicare Benefit Policy Manual, Hospital Services Covered Under Part B [.pdf, 162KB] Chapter 18, Medicare Claims Processing Manual, Preventive and Screening Services [.pdf,789KB] Preventive Services Educational Products For Health Care Professionas [.pdf, 36.1KB] Medicare Learning Network
Related Links Outside CMS
U.S. Preventive Services Task Force--Colorectal Cancer Screening Recommendations Centers for Disease Control and Prevention--Colorectal Cancer Information National Cancer Institute--Information on Colon and Rectal Cancer The Community Guide--Cancer Screening Recommendations Partnership for Prevention--Priorities for Increasing Use of Clinical Preventive Services

Page Last Modified: 07/13/2009 8:03:57 AM
Help with File Formats and Plug-Ins