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Colorectal Screening Cost-Sharing Changes Are Coming

Colorectal Screening Cost-Sharing Changes Are Coming

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 YearCopay
202220%
2023-202615%
2027-202910%
2030 and beyond0%

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:

https://www.cms.gov/files/document/mm12656-changes-beneficiary-coinsurance-additional-procedures-furnished-during-same-clinical.pdf

Lee Fifield
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About Has 143 Posts

Lee Fifield has a Bachelor of Science in communications from Ithaca College, Ithaca, New York, and has worked as a writer and editor for 17 years.

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