Colorectal Screening Cost-Sharing Changes Are Coming
- By Lee Fifield
- In Billing
- November 29, 2022
- No Comments
Colonoscopies that require additional related procedures will soon see a change in Medicare coinsurance.
A provision of the Consolidated Appropriations Act (CAA) of 2021 has put Medicare patients on a gradual coinsurance reduction plan for certain colorectal cancer screening tests that turn into a diagnostic or therapeutic service. Currently, the addition of any procedure beyond a planned colorectal cancer screening test (for which there is no coinsurance) results in the patient having to pay a 20 percent coinsurance (i.e., copay). Section 122 of the CAA will gradually reduce the amount of this coinsurance until it’s free for dates of service on or after Jan. 1, 2030.
Rate Reduction
For services furnished during 2022, the copay amount for colorectal cancer screening tests that require additional related procedures will continue to be 20 percent. For 2023 through 2029, the copy will be gradually phased out. Beginning in 2030, the amount a Medicare patient pays will be 0 percent.
| Service Year | Copay |
| 2022 | 20% |
| 2023-2026 | 15% |
| 2027-2029 | 10% |
| 2030 and beyond | 0% |
Procedures Affected
The reduced coinsurance applies to the following three procedures:
G0104 Colorectal cancer screening; flexible sigmoidoscopy
G0105 Colorectal cancer screening; colonoscopy on individual at high risk
G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk
When the PT modifier is appended to one of the above codes on a claim and submitted on the line item with HCPCS Level II codes 10000-69999, G0500, 00811, or CPT® code 99153 to indicate that the screening procedure has become a diagnostic or therapeutic service, the coinsurance amount will be reduced or waived depending on the date of service billed (see the above chart).
See MLN Matters article MM12656 and the Centers for Medicare & Medicaid Services (CMS) notification CR 12656 for further details.
Resource:
- Advice From a COBGC™ - January 3, 2023
- I Am AAPC: Gloria Nwanna, CPC - January 3, 2023
- Member of the Month: Gabriel Aponte-Moberg - January 3, 2023
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