Gastroenterology Coding Alert

Question: Can we perform a colorectal cancer screening on a 51-year-old patient every year? Or is it every three years?

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Answer: The answer depends on which type of screening test you perform, and could also involve the patient’s risk level.

If you perform the screening using Cologuard on an asymptomatic patient between 50 and 85 years of age at average risk of developing colorectal cancer, Medicare will cover it once every three years, according to CMS’ “Medicare Preventive Services” fact sheet.

If you perform a screening colonoscopy, FOBT, flexible sigmoidoscopy, or barium enema on a Medicare patient who is either at high risk of developing colorectal cancer or aged 50 or older at normal risk, the following frequency guidelines apply, CMS says in the fact sheet:

Normal (Average) Risk:

• Screening FOBT: Annually
• Screening flexible sigmoidoscopy: Once every four years (unless a screening colonoscopy was performed, in which case Medicare may cover a screening flexible sigmoidoscopy only after at least 119 months)
• Screening colonoscopy: Every 10 years (unless a screening flexible sigmoidoscopy was performed, in which case Medicare may cover a screening colonoscopy only after 47 months)
• Screening barium enema (As an alternative to covered screening flexible sigmoidoscopy)

High Risk:

• Screening FOBT: Annually
• Screening flexible sigmoidoscopy: Once every 4 years
• Screening colonoscopy: Every 2 years (unless a screening flexible sigmoidoscopy was performed in which case Medicare may cover a screening colonoscopy only after at least 47 months). The appropriate interval might be two years for long-standing ulcerative colitis or familial polyposis syndromes. However, most High Risk screening examinations are done because a Personal History of Colon Polyps or a Family History of Colon Cancer where the appropriate interval is 5 years.
• Screening barium enema (As an alternative to covered screening flexible sigmoidoscopy or colonoscopy)

If you use the above criteria, you can easily pinpoint the frequency for the test you performed based on the patient’s risk status.

Reference: To read the complete fact sheet on colorectal cancer screening, visit the CMS website at https://www.cms.gov/Medicare/Prevention/Prevntion­GenInfo/medicare-preventive-services/MPS-QuickRef­erenceChart-1.html#COLO_CAN.