Gastroenterology Coding Alert

The debate over colonography continues.

Medicare has proposed not to pay for so-called virtual colonoscopies because there is not enough evidence that they would benefit people ages 65 and older.

Here the wording from the CMS proposed decision memo:

The evidence is inadequate to conclude that CT colonography is an appropriate colorectal cancer screening test under §1861(pp)(1) of the Social Security Act. CT colonography for colorectal cancer screening remains noncovered.

Medicares move has drawn praise and condemnation. The New York Times supports the move.Eliminating unproven procedures and reducing needless costs is necessary if the nation is to improve the quality and lower the cost of care overall, said an editorial.

The American Society of Gastroenterological Endoscopists backs it, too. Many of the studies that support colonography were conducted on younger patients than Medicare recipients, ASGE President JohnL. Petrini, MD, FASGE, pointed out in a letter to CMS. Younger individuals have a lower prevalence of polyps, lower test-positive rates and lower rates of referral for optical colonoscopy with polypectomy, Petrini wrote.

Opposition Lets Itself Be Heard

That may be disappointing for older Americans who would prefer a virtual exam to a real one. Patients whove had both colonographies and colonoscopies prefer virtual colonoscopy, ECRI Institute said in a recent study. But ECRI, a nonprofit, evidence-based practice center, didnt have enough data to tell whether offering CT colonography increases patient participation in colorectal cancer screening.

The public comment section on Medicares Web site is full of outraged doctors. Many point to studies that suggest virtual colonoscopies are at least as effective as endoscopies.

Other screening tests such as stool tests or flexible sigmoidoscopy or barium enema that Medicare does pay for have much higher miss rates for diminutive polyps, wrote Dennis Ahnen, MD, staff physician at the Denver Veterans Affairs Medical Center and professor of medicine at the University of Colorado Denver School of Medicine.

One of the knocks on virtual colonoscopy is that it may miss smaller polyps.

Polypectomy of small polyps is associated with measurable risk, while the potential for future malignancy is very low, counters William Blanchet, MD, a physician in Boulder, Colo. Fewer than 1 percent of adenomatous polyps less than 1 centimeter will eventually develop into cancer.

How to Code VC & for Now

As Gastroenterology Coding Alert, Vol. 11, No. 4 reported, several Medicare carriers will in special circumstances accept category III (temporary) codes 0066T (Computed tomographic [CT] colonography [i.e., virtual colonoscopy]; screening) or 0067T (...diagnostic) for CT colonography. But youll have to document a failed instrument colonoscopy to expect reimbursement for virtual colonoscopy claims.

Caution: Coverage for 0066T and 0067T is far from universal, with many Medicare carriers holding out. The bottom line? Check with your carrier for coverage before reporting these codes. You may have to get a predetermination from your carrier.