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Changes to Beneficiary Coinsurance When Colorectal Cancer Screenings Become Diagnostic

Changes to Beneficiary Coinsurance When Colorectal Cancer Screenings Become Diagnostic

A small provision of the 2021 Consolidated Appropriations Act (CAA) paves the way for Medicare patients to eventually pay no coinsurance for colorectal cancer screening tests when they become diagnostic. The Centers for Medicare and Medicaid Services (CMS) finalized how that guideline will be enacted in the 2022 Medicare Physician Fee Schedule.

Changes To Coinsurance Amounts

More specifically, Section 122 of the CAA–a $2.3 trillion spending bill that combines $900 billion in COVID-19 stimulus relief with a $1.4 trillion omnibus spending bill for 2021–includes a special coinsurance rule for procedures that are planned as colorectal cancer screening tests (“flexible screening sigmoidoscopies” and “screening colonoscopies, including anesthesia furnished in conjunction with the service”) but become diagnostic tests when the practitioner identifies the need for additional services (e.g., removal of polyps). 

Previously, the addition of any procedure beyond the planned colorectal screening (for which there is no coinsurance) resulted in the beneficiary having to pay a 20 percent coinsurance, though the Part B deductible doesn’t apply. However, Section 122 of the CAA gradually reduces the amount of coinsurance a beneficiary will pay for such services.

For services furnished during 2022, the coinsurance amount paid for planned colorectal cancer screening tests that require additional related procedures will continue to be 20 percent. For 2023 through 2026, the amount will be 15 percent. For 2027 through 2029, the amount will be 10 percent. And beginning in 2030, the amount will be 0 percent.


Procedures Included

According to CMS, the reduction of the coinsurance percentage will hold true regardless of the code that is billed–for diagnosis, removal of tissue or other matter, or another procedure furnished in the same encounter as the screening. In essence, “all surgical services furnished on the same date as a planned screening colonoscopy or planned flexible sigmoidoscopy would be viewed as being furnished in connection with, as a result of, and in the same clinical encounter as the screening test” for purposes of these guidelines, CMS says. 

Also, as mentioned earlier, these new guidelines also apply to anesthesia services administered during colonoscopy.

Coding Guidelines

The new guidelines do not change the coding requirements for screening colonoscopies. Providers must continue to report HCPCS modifier ‘‘PT’’ to indicate that a planned colorectal cancer screening service has been converted to a diagnostic service. 

Specifically for anesthesia services furnished in conjunction with screening colonoscopies, anesthesiologists should continue to use the following: 

  • CPT code 00812 (Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum; screening colonoscopy) for screening colonoscopies that do not convert to diagnostic. Medicare will waive the deductible and coinsurance when paying for the anesthesia service.
  • CPT code 00811 (Anesthesia for lower intestinal endoscopic procedures, endoscopy introduced distal to duodenum; not otherwise specified) and with the PT modifier for screening colonoscopies that began as screening and later converted to diagnostic. Medicare will waive the deductible and use the gradually decreasing coinsurance amounts when paying for the anesthesia service.

As well, CMS said they will monitor “for any increases in surgical services unrelated to the colorectal cancer screening test performed on the same date as the screening test,” and if any notable increases or abuses of the policy are detected, guidelines may be revised further during future rulemaking.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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