Gastroenterology Coding Alert

Question: Is there a change this year in how Medicare pays for colorectal cancer screening colonoscopy that results in a biopsy or polyp removal?

Texas Subscriber

Answer: Medicare isn’t changing anything for 2021, but the Consolidated Appropriations Act, 2021 (CAA) provides a schedule for upcoming changes to coverage.

At issue are cases like you’ve described, when the beneficiary presents for a screening colonoscopy (with no history or symptoms), but the gastroenterologist finds a polyp or anomaly and takes a surgical specimen for pathological diagnosis.

Look back: The problem in such a scenario has been that Medicare covers screening colonoscopy at 100 percent, but has cost sharing for diagnostic colonoscopy (when the gastroenterologist finds something and takes a specimen), including deductibles and copays. That results in unexpected billing to the patient.

To rectify this, CMS is implementing the following schedule to waive Medicare coinsurance for these colorectal cancer screening tests when a polyp is removed by gradually increasing coverage percentage as follows:

• Jan. 1, 2022: 80 percent
• Jan. 1 2023-2026: 85 percent
• Jan. 1 2027-2029: 90 percent
• Jan. 1, 2030: 100 percent

Therefore, by 2030, the patient will have no coinsurance due under Medicare when colorectal screenings are performed — whether or not a polyp is removed.