Medicare and Colonoscopy: When Screening Turns Diagnostic

Medicare Colon Cancer Screening Colonosocpy
Medicare offers screening for colorectal cancer. Peter Cade / The Image Bank / Getty Images

Getting a colonoscopy is not going to make anyone's list of favorite things to do. That doesn't mean the procedure is any less important to your health. For example, colon polyps that could turn into cancer can be removed during this procedure.

Catching colon cancer in its early stages—especially before it has had the chance to spread—can allow for more effective treatments to be used upfront. The difference, in some cases, could mean life and death.

The National Cancer Institute reports that colorectal cancer is the fourth most common cancer and the third most lethal cancer in the US. With more than 134,000 people diagnosed and 49,000 dying from the disease every year, screening is more important than ever.

Medicare recognizes the importance of preventive medicine and added coverage for screening colonoscopy back in 2001. Colonoscopy screening is now offered free to beneficiaries if their doctor accepts assignment. This means that the doctor agrees not to charge more than Medicare's recommended rates for any care he/she provides.

Medicare Coverage for Colon Cancer Screening

While there are other tests that can be used to screen for colon cancer, colonoscopy remains the only test that allows a doctor to visualize the full length of the colon and to biopsy or remove suspicious findings at the time of examination. 

If you are squeamish about getting a colonoscopy, the good news is that Medicare covers more than one option for colon cancer screening.

And coverage is available to beneficiaries 50 years and older as well as to certain individuals who may be at higher risk based on family history and other factors.

 

Colon Cancer Screening Tests Covered by Medicare
TestWhat Is It?ProsCons
Barium enema

An X-ray of the abdomen after barium contrast has been inserted into the rectum

Can detect gross abnormalities in the colonMay be unable to detect small anatomic changes like colon polyps which could result in false negative results 
ColonoscopyA procedure that inserts a long flexible camera into the rectum to examine the colon Directly visualizes the full length of the colon, biopsies can be performed as neededRisk for colon injury during the procedure
Fecal occult blood testA chemical assay used to look for blood in a stool sampleNon-invasiveFrequent false positive results
Flexible sigmoidoscopyA procedure that inserts a long flexible camera into the rectum to examine the colonDirectly visualizes part of the colon, biopsies can be performed as neededRisk for colon injury during the procedure, does not examine the full length of the colon which could result in false negative results
Stool DNA testA laboratory test that looks for DNA changes in a stool sampleNon-invasiveLimited to people at average risk for colon cancer who are 50-85 years old and without symptoms, including a negative fecal occult blood test

 

Each of these tests is included as part of Medicare's preventive screening initiative but not all of them are free.

 

Cost and Frequency of Colon Cancer Screening in Medicare
TestCostFrequency
Barium enema20 percent coinsuranceEvery 48 months or every 24 months for those at high risk for colon cancer
ColonoscopyFree if your doctor accepts assignmentEvery 120 months or 48 months after a flexible sigmoidoscopy or every 24 months for those at high risk for colon cancer
Fecal occult blood testFreeEvery 12 months
Flexible sigmoidoscopyFree if your doctor accepts assignmentEvery 48 months or 120 months after a screening colonoscopy 
Stool DNA testFree if you meet criteriaEvery 3 years

 

With the exception of flexible sigmoidoscopy, you are likely to need a colonoscopy if any of these tests are positive. A tissue sample is needed to make a diagnosis of colon cancer and colonoscopy and flexible sigmoidoscopy are the only screening tools that allow for a biopsy.

When Screening Turns Diagnostic

A screening colonoscopy can sometimes cost a lot of money even if you have insurance.

Depending on where you live in the country and who performs the procedure, a screening could cost anywhere from nothing to thousands of dollars. Thankfully, Medicare offers the screening test free to beneficiaries if their doctor agrees to Medicare's Physician Free Schedule.

A cost issue arises, however, when a Medicare-covered screening test turns diagnostic. While certain screening tests are free, you may be required to pay a 20 percent coinsurance for diagnostic tests. That could be a significant amount to pay if your study costs $2,000 or more.

In simplest terms, a screening test is one that looks for disease in the absence of signs and symptoms, while a diagnostic test is performed in the presence of signs and symptoms. When a screening colonoscopy identifies a colon polyp—a possible sign of colon cancer—it becomes a diagnostic study. What makes a diagnostic colonoscopy distinct from a screening test is that it adds on extra services, namely biopsy and polyp removal. The doctor is no longer looking to screen for a condition. He/she has found something abnormal and now needs to make a diagnosis.

Many medical organizations such as the American College of Gastroenterology and American Gastroenterological Association state that polyp removal is an essential component of any colonoscopy evaluation and should be considered an inherent extension of that test. The Affordable Care Act agrees that insurers should not charge an additional coinsurance or copayment for polyp removal as a measure of preventive screening. A study ordered as a diagnostic study, on the other hand, would be subject to those added fees.

Unfortunately, the Affordable Care Act applies to private health plans but not to Medicare. Medicare continues to charge coinsurance for colonoscopies they classify as diagnostic and that includes any exam that performs biopsies or removes colon polyps, whether or not the procedure was ordered as part of a routine screening assessment.

Effects of Colon Cancer Screening

Medicare began to offer screening colonoscopies as a free preventive service back in 2011. Since that time, beneficiaries—particularly men—have taken advantage of the benefit. There has been a 20 percent increase in Medicare colonoscopy screening rates. Despite the uptick in screening, as many as 40 percent of people do not get the recommended testing.

Colonoscopy saves lives, decreasing the incidence and mortality of colorectal cancer by 61 percent. While the cost of diagnostic colonoscopies may be cost prohibitive for some beneficiaries, there is hope that legislative changes in the future will decrease that burden by adding more colonoscopy services to Medicare's preventive repertoire. In the meantime, it is important to note that screening is available, it is covered, and it could save your life.

Sources:

Hamman MK, Kapinos K. Affordable Care Act Provision Lowered Out-Of-Pocket Cost And Increased Colonoscopy Rates Among Men In Medicare . Health Aff December 2015; 34:2069-2076. doi:10.1377/hlthaff.2015.0571.

Medicare.gov. Colorectal cancer screenings. https://www.medicare.gov/coverage/colorectal-cancer-screenings.html. Accessed May 24, 2016.

National Cancer Institute Surveillance, Epidemiology and End Results Program. SEER Stat Fact Sheets: Colon and Rectum Cancer. http://seer.cancer.gov/statfacts/html/colorect.html. Accessed May 24, 2016.

Pan J, Xin L, Ma Y, Hu L, Li Z. Colonoscopy Reduces Colorectal Cancer Incidence and Mortality in Patients With Non-Malignant Findings: A Meta-Analysis. Am J Gastroenterol 2016; 111:355–365; doi:10.1038/ajg.2015.418.

U.S. Department of Labor. FAQs about Affordable Care Act Implementation Part XII. https://www.dol.gov/ebsa/faqs/faq-aca12.html. Published February 20, 2013. Accessed June 5, 2016.

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