Medicare Screening Colonoscopy Coverage

The Centers for Medicare & Medicaid Services (CMS) pays 100 percent of the Medicare-approved amount for fecal occult blood tests, flexible sigmoidoscopies, colonoscopies, and multi-target stool DNA tests, and 80 percent for barium enemas. A Part B deductible does not apply, in any case; however, coinsurance applies to colonoscopies and sigmoidoscopies performed in ambulatory surgical centers and non-Outpatient Prospective Payment System hospitals.
Conditions of coverage for colorectal screening tests include age and frequency:

• Fecal occult blood test: Medicare covers this lab test once every 12 months for beneficiaries beginning at age 50. Effective January 27, 2014, ultrasound screening for screening FOBTs is also a covered benefit.
• Barium enema: Medicare covers this test once every 48 months for normal-risk beneficiaries aged 50 or older; and for beneficiaries at high risk, once every 24 months. (There is no minimum age requirement for high-risk individuals to receive a barium enema in place of a screening colonoscopy.)
• Colonoscopy: Medicare covers this test once every 120 months or once every 48 months after a previous flexible sigmoidoscopy; and for beneficiaries at high risk, once every 24 months. (There is no minimum age requirement for high-risk individuals to receive a screening colonoscopy.) Coverage for normal-risk individuals began July 1, 2001.

Additionally, beneficiary coinsurance and deductible are waived for anesthesia service 00810 Anesthesia for lower intestinal endoscopic procedures, endoscope introduced distal to duodenum when performed in with a screening colonoscopy.

• Flexible sigmoidoscopy: Medicare covers this test once every 48 months for most beneficiaries over age 50. For normal-risk patients, Medicare covers this test 120 months after a previous screening colonoscopy.
• Multi-target stool DNA test: Effective January 1, 2015 Medicare covers this type of test once every 36 months when the following conditions are met:
  • Age 50-85 years
  • No signs or symptoms of colorectal disease
  • At average risk, meaning:
    • No personal history of adenomatous polyps, colorectal cancer, inflammatory bowel disease, including Crohn’s disease and ulcerative colitis
    • No family history of colorectal cancers or adenomatous polyps, familial adenomatous polyposis, or hereditary nonpolyposis colorectal cancer

Defining High Risk

Per CMS, a patient is high risk for colorectal cancer if he or she has 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 inflammatory bowel disease, including Crohn’s disease and ulcerative colitis.

Note: Private payer policies may differ. For example, Aetna considers colorectal cancer screening beginning at age 45 a medically necessary preventive service for African Americans because of the high incidence rate of colorectal cancer in this population.
Another condition of payment is a written order from the beneficiary’s attending physician, or for claims with dates of service on or after January 27, 2014, the beneficiary’s attending physician assistant, nurse practitioner, or clinical nurse specialist.

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John Verhovshek

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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