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Reduced Co-Insurance for Screening Colonoscopies

Reduced Co-Insurance for Screening Colonoscopies

As per the update dated 29th April 2022, CMS reduced the coinsurance for certain screening flexible sigmoidoscopies and screening colonoscopies. This special coinsurance applies regardless of the code you bill for the establishment of a diagnosis as a result of the test, or for the removal of tissue or other matter or other procedure. It’s effective when provided in connection with, as a result of, and in the same clinical encounter as the colorectal cancer screening test. The reduced coinsurance is being phased-in beginning January 1, 2022. Currently, the addition of any procedure beyond a planned colorectal cancer screening test (for which there’s no coinsurance) results in the patient having to pay coinsurance. CMS is planning to gradually reduce this coinsurance until it’s completely free for dates of service on or after January 1, 2030.

Effective January 1, 2022, when a screening colorectal cancer procedure, G0104, G0105, or G0121 has the PT modifier submitted on the claim line item with HCPCS codes 10000 – 69999, G0500, 00811, or CPT code 99153 for diagnostic colonoscopy, or diagnostic flexible sigmoidoscopy, or other procedure to indicate that a screening colorectal cancer procedure HCPCS G0104, G0105, or G0121, has become a diagnostic or therapeutic service, coinsurance is reduced or waived for claims as follows:

  • For dates of service in calendar years 2023-2026, the reduced coinsurance is 15%
  • For dates of service calendar years 2027-2029, the reduced coinsurance is 10%
  • For dates of service on or after calendar year 2030, Medicare waives the coinsurance

Background for Reduced Co-Insurance

Section 4104 of the Affordable Care Act (ACA) defined the term ‘preventive services’ to include ‘colorectal cancer screening tests’ and, as a result, it waives any coinsurance that would otherwise apply under Section 1833(a)(1) of the Social Security Act for screening colonoscopies. In addition, the ACA amended Section 1833(b)(1) of the Act to waive the Part B deductible for screening colonoscopies, which includes moderate sedation services as an inherent part of the screening colonoscopy procedural service. These provisions are effective for services furnished on or after January 1, 2011.

In the CY 2017 PFS Final Rule, the Centers for Medicare & Medicaid Services (CMS) modified coding and reporting of procedural services that include moderate sedation as an inherent part of the service, including for screening colonoscopies. CR 10075 operationalizes the existing waiver of deductible and coinsurance for moderate sedation services furnished in conjunction with and in support of colorectal cancer screening tests. Effective January 1, 2017, beneficiary coinsurance and deductible continues to not apply to the following moderate sedation claim lines when furnished in conjunction with screening colonoscopy services and when billed with Modifier 33 or Modifier PT:

  • HCPCS code G0500: Moderate sedation services provided by the same physician or other qualified health care professional performing a gastrointestinal endoscopic service that sedation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; patient age 5 years or older (additional time may be reported with 99153, as appropriate).
  • CPT code 99153: Moderate sedation services provided by the same physician or other qualified healthcare professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent, trained observer to assist in the monitoring of the patient’s level of consciousness and physiological status; each additional 15 minutes of intra-service time (List separately in addition to code for primary service)

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Reference: https://www.cms.gov/files/document/mm12656-changes-beneficiary-coinsurance-additional-procedures-furnished-during-same-clinical.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM10075.pdf

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