Question: In Ambulatory Coding and Payment Report (Vol. 13, No. 4, pages 27-28), you advised that Medicare will cover a colorectal cancer screen once every 10 years for average-risk patients age 50 or older. I have heard that there are exceptions to this rule for patients who have received a previous sigmoidoscopy. Is this correct?
New Jersey Subscriber
Answer: You are correct that a previous sigmoid-oscopy may change a patient’s eligibility for a Medicare-covered screening colonoscopy (G0121, Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk).
If your patient has had a Medicare-covered cancer screening via flexible sigmoidoscopy (G0104, Colorectal cancer screening; flexible sigmoidoscopy) within the last 48 months, he is not eligible for a colonoscopy screening.
According to Medicare, average-risk patients who have had covered flexible sigmoidoscopy screenings must wait four years before having a covered colonoscopy screening.
Therefore, if a 54-year-old average-risk Medicare patient had a flexible sigmoidoscopy screening on May 5, 2004, he would not be eligible for a covered screening colonoscopy until at least May 5, 2008.
