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Coverage of Colonoscopies Under the Affordable Care Act's Prevention Benefit

Colorectal Cancer in the United States

Colorectal cancer is the third most common cancer and cause of death from cancer in men and women in the United States.1 It is estimated that over 143,000 people will be diagnosed with colorectal cancer and almost 52,000 will die from this disease in 2012. Treatment costs can be very high, especially for advanced forms of colorectal cancer. Estimates suggest that about $12.2 billion is spent on treatment for colorectal cancer each year in the United States, and annual treatment costs for an advanced case may exceed $300,000 for a year.2

Costs associated with advanced treatment and premature deaths due to colorectal cancer are largely avoidable. Regular screening can identify colorectal cancer at early stages when it is easiest and least expensive to treat and when the possibility of cure is the greatest. In addition, regular screening can actually prevent colon cancer by detecting and removing precancerous polyps (abnormal growths in the lining of the colon), eliminating the possibility that they may progress to cancer. The USPSTF and other expert medical and scientific panels issue evidence-based recommendations about colorectal cancer screening.3 Yet, many Americans do not receive colorectal screenings as recommended and one in three adults between the ages of 50 and 75 were not up-to-date with recommended colorectal cancer screening in 2010.4

Colonoscopy is one of the more expensive preventive services covered under the ACA; charges can range from $1,000 to $2,000 or more.5 Adults concerned about their liability for these charges could be discouraged from seeking screening. In a recent survey of the National Colorectal Cancer Screening Network, which represents public health and health care professionals who deliver such services, 80 percent of respondents indicated they were aware of problems with insured patients encountering unexpected cost-sharing for screening colonoscopy.6 In the same survey, 70 percent of respondents said they thought the potential of unexpected costs would deter some individuals from being screened.

Screening Colonoscopy and Cost-Sharing: Results from Three Scenarios

Asymptomatic individuals (that is, adults showing no signs or symptoms of disease) may encounter unexpected cost-sharing for a screening colonoscopy in three clinical circumstances described below.

  1. Polyp Removal During Screening Colonoscopy
Polyp Removal. Bill, who lives in Arizona, has health insurance that covers preventive services without cost-sharing. Both his insurance agent and plan materials indicated that colonoscopy would be fully covered. As recommended by his doctor, Bill went for a routine screening colonoscopy. During the exam, the doctor identified and removed two benign polyps. Soon after, Bill received a bill from his insurer for $1,100 indicating that his deductible would apply for this procedure. He disputed the charge and his insurer eventually reversed its decision.

Most colorectal cancers result from abnormal growths (“adenomatous polyps”) in the lining of the colon that become cancerous over time.7 Because most of these polyps can be identified and removed during a colonoscopy, in many cases, colorectal cancer is preventable through timely screening.8,9

Polyp removal is a routine part of screening taking place in approximately half of screening colonoscopies for patients who are at average risk of developing colorectal cancer.10,11 Of the polyps removed, about half are adenomatous polyps, which have the potential to become cancerous. Physicians cannot reliably distinguish adenomatous polyps from harmless, benign polyps during colonoscopy, and so typically remove all polyps identified during a screening colonoscopy.

USPSTF recommendations – The USPSTF recommendations underscore that removal of polyps is central to making screening colonoscopy a highly effective preventive health care service. According to the USPSTF, “[s]creening for colorectal cancer reduces mortality through detection and treatment of early-stage cancer and detection and removal of adenomatous polyps” (emphasis added).12

Despite its inherently preventive nature and frequent occurrence, polyp removal during screening colonoscopy is sometimes subject to cost-sharing by private health plans. Inconsistency in how insurers define covered “screening” services (that is, whether or not the intent of the exam in an asymptomatic adult is superseded by clinical findings), as well as non-standard billing code practices of insurers and providers, contribute to this result.

Definition of screening – According to medical experts, screening is defined by the population to which a test is applied (i.e., individuals who are asymptomatic), not the findings that result from the test itself.13 In the context of colorectal cancer, this definition indicates that “screening” would describe a colonoscopy that is routinely performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps. Whether a polyp or cancer is ultimately found should not change the screening intent of that procedure.
This definition of screening is widely accepted in the medical and public health arenas, but is not consistently captured as such within the current medical billing and coding system and is not necessarily embraced by all health plans. Several insurers interviewed reported that cost-sharing should be determined by whether patients were asymptomatic at the time they underwent colonoscopy—i.e., the procedure was for screening – even if a polyp was removed. Other insurers said while they consider screening colonoscopies to be a preventive service regardless of polyp removal, their claims payment systems apply cost-sharing depending on how providers code the procedure.

Variation in coding practices – Claims submitted to a health insurer for reimbursement must be accompanied by billing codes that identify the service provided. So far, no consistent coding methodology is used either by all private insurers or providers to identify the preventive care and screening services that must be provided without cost-sharing as a result of the ACA. As one billing expert noted, this isn’t surprising if one considers that the current coding methodologies were first developed when health insurance tended not to cover preventive care.

Recently there have been efforts by the American Medical Association (AMA) to modify the Current Procedural Terminology (CPT) coding system to clearly designate preventive services that should be covered without cost-sharing. In direct response to the new ACA requirement, CPT modifier 33 was created to allow providers to identify to insurance payers and providers that the service was preventive under applicable laws, and that patient cost-sharing does not apply. The AMA writes that the modifier “may be used when a service was initiated as a preventive service, which then resulted in a conversion to a therapeutic service. The most notable example of this is screening colonoscopy (code 45378), which results in a polypectomy (code 45383).”14 (See Appendix A for further discussion of coding methodology.)

Insurers vary, however, in the coding methods they use and in what codes their claims payment systems can accommodate. Some insurers have encouraged providers to use CPT modifier 33, but another medical director cautioned that claims systems vary widely and not all insurers’ systems are designed to use this modifier. Insurers might also direct providers to indicate that the colonoscopy was a screening service through use of ICD-9 diagnosis codes known as “V” codes. However doctors can vary in the diagnosis code they assign (or the order in which they assign multiple diagnosis codes) when a screening colonoscopy involves polyp removal.

Insurers also vary in the guidance they offer providers on how to code screening colonoscopy with polypectomy. For example, a representative of one large group practice described the variation in coding guidance received from the dozen private health insurers that cover the group’s patients: five insurers indicated that practices should code all screening colonoscopies as a preventive service, whether or not polyps are removed, so the insurers will know to waive cost-sharing; two insurers advised practices to code screening colonoscopies as therapeutic when polyps are removed; and the remaining five insurers had offered no guidance on this issue.

Insurer payment practices vary – Interviews with medical directors for seven major health insurers in four states found variation in how insurers impose cost-sharing when a polyp is removed during a screening colonoscopy. Four insurers always waive cost-sharing. According to one, “[w]e don’t care what the reasons are; if it’s a colonoscopy, we’re not going to impose cost-sharing.” Three other insurers waive cost-sharing if the provider codes the procedure to indicate a screening colonoscopy. One of the insurers that always waives cost-sharing has recently arrived at this decision and previously viewed polypectomy as therapeutic. This insurer is working on a new system to identify the intent of the screening colonoscopy, even when a polyp is found and participating providers code the procedure differently.

Insurer Payment Practices for Screening Colonoscopy with Polyp Removal
State/Insurer Insurer Imposes Cost-sharing?
New Mexico
Insurer A No
Insurer B No
Insurer C No
Insurer D Depends on provider coding
Insurer E Depends on provider codingurer Fn codingee definition above, mdefinition ofpy].”ven a difference bw lonoscopy.tent of the procedurebecause it actually
Insurer F No
Insurer G Depends on provider coding

Three other insurers that always waive cost-sharing have adjusted their claims payment systems to provide full coverage for colonoscopy with polyp removal regardless of how the provider codes. Their medical directors reported that this was a business decision, made in the absence of federal guidance regarding the ACA requirement, adopted to reduce provider and enrollee complaints, appeals, and their associated administrative burdens. One director commented this approach also simplified the “impossible” task of distinguishing between preventive services and diagnostic services that left patients “caught in the middle.” These insurers stressed the clinical importance of promoting screening to prevent colorectal cancer. As one put it, “[i]f this is really about prevention and about patients … it’s just the right thing to do.”

Another medical director echoed this sentiment, “[Polyp removal] is exactly why you’re doing this … If you take that polyp out, you have prevented the cancer.” Even so, his plan imposes cost-sharing when providers do not code the procedure using CPT modifier 33. Although the insurer has encouraged providers to code the service as preventive, in practice, not all of them use this modifier and when they don’t, patients may owe hundreds of dollars or more when cost-sharing is applied.

  1. Colonoscopy as Follow-up to a Positive Stool Blood Test, other Colorectal Cancer Screening Test

The USPSTF gives an “A” recommendation to two other colorectal cancer screening procedures in addition to colonoscopy – high-sensitivity fecal occult blood test (FOBT) and flexible sigmoidoscopy for most adults 50 years of age until 75 years of age.15 For these procedures, the USPSTF recommends high-sensitivity FOBT on an annual basis or flexible sigmoidoscopy every 5 years combined with high-sensitivity FOBT every 3 years. A high-sensitivity FOBT detects microscopic bleeding that patients would otherwise not notice because it is not visible in the stool. These other procedures are less invasive, pose lower risk of complication, and may be elected by patients and providers for other reasons, such as local test availability or quality and patient preference.

USPSTF recommendations – With respect to these procedures, the USPSTF notes that “follow-up of positive screening test results requires colonoscopy regardless of the screening test used” (emphasis added).16   This is because a positive FOBT indicates the possible presence of a cancer or adenomatous polyp, but the screening process is not complete until the patient undergoes a colonoscopy to determine if the initial test was a true or false positive.

Insurers have adopted different approaches regarding cost-sharing for a screening colonoscopy following a positive FOBT. They vary based on whether the colonoscopy is considered part of the colorectal screening exam, or a separate, diagnostic procedure.

Screening continuum – According to medical experts, cancer screening may be best understood as a stepwise continuum that typically begins with a clinician’s recommendation that an individual without symptoms get tested and concludes with the outcome of the test(s). As one put it, “screening is not a single test, but rather a cascade of events.”17 The USPSTF recommendations are consistent with this notion, writing that “[c]olonoscopy is a necessary step in any screening program that reduces mortality from colorectal cancer” (emphasis added).18

This suggests that follow-up colonoscopy after a positive FOBT is integral to the screening process and a necessary component of screening. The 2008 Joint Guidelines issued by the American Cancer Society, the United States Multisociety Task Force on Colorectal Cancer (ACS/MSTF) and the American College of Radiology reinforce the importance of the screening continuum by emphasizing that patients with a positive FOBT need follow-up colonoscopy.19 From a prevention perspective, a screening test would not be considered successful if the follow-up colonoscopy were not performed to identify cancer and/or remove polyps that may have caused the positive FOBT in the first place.

Not all providers or insurers subscribe to this concept of the screening continuum. Some regard colonoscopy as a diagnostic service if it follows a positive FOBT. In their view the patient seeking the colonoscopy is no longer asymptomatic; the blood in the stool test (even though the patient was not aware of it before the test) is a sign that additional testing is needed. Interestingly, however, the FOBT can sometimes yield a false positive reading, and a follow-up colonoscopy would show normal results. In such cases, the health plan might apply cost-sharing to the follow-up colonoscopy which would have been free of cost-sharing had the patient chosen colonoscopy in the first place.

Insurer payment practices vary – Four insurers reported that they do not impose cost-sharing for a colonoscopy following a positive FOBT, while three insurers always impose cost-sharing. Despite believing that a follow-up colonoscopy would be diagnostic, one medical director noted that his company does not match screenings to positive lab tests so, in practice, the patient might avoid cost-sharing if the doctor codes it as a screening procedure.

Insurer Payment Practices for Screening Colonoscopy Following Positive FOBT
State/Insurer Insurer Imposes Cost-sharing?
New Mexico
Insurer A No
Insurer B No
Insurer C Yes
Insurer D No
Insurer E Yes
Insurer F No
Insurer G Yes
  1. Screening Colonoscopy in Individuals at Increased Risk
Surveillance – Personal History. Sarah, who lives in New Hampshire, has a history of colon polyps and receives routine colonoscopies every 5 years. At her most recent screening, she confirmed with her provider that the screening would be covered at no charge to her under the new provisions of the ACA. He said he thought it would, but had heard of patients being charged if polyps were removed. So Sarah asked her insurer, who said colonoscopies were fully covered even if polyps were removed. Sarah went ahead with the procedure. A few weeks later, her insurance statement indicated her deductible applied, and Sarah owed $1,300. She also received a bill for over $600.00 from the anesthesiologist. Sarah learned her screening had been coded as “diagnostic” based on her personal history, and was therefore billable. She notified her insurer that this was a routine “surveillance” colonoscopy and should be fully covered under the ACA preventive benefit. Eventually she was able to get all charges removed but wonders if other patients would be as informed and capable of self-advocating.

For the general population, the USPSTF recommends a screening colonoscopy every 10 years, beginning at age 50 and ending at age 75.20 However, some individuals are at increased risk for colorectal cancer because they have a family or personal history of the disease or of adenomatous colon polyps. Based on the nature of the family or personal history, screening before the age of 50 and/or at higher frequency (e.g., 5 years vs. 10 years) may be recommended; for other patients screening initiation and frequency remains the same, but the individual is advised to have a screening colonoscopy rather than other testing options. With the exception of individuals with exceptionally high risk due to inherited genetic syndromes, most individuals at increased risk still will not develop colorectal cancer in their lifetime and, like average risk individuals, will be asymptomatic at the time of their screening exams.

Screening for individuals who are at an increased risk due to a personal history of colorectal cancer or adenomatous polyps is also referred to as “surveillance screening” and may be coded as diagnostic despite the fact that the patient is asymptomatic. In addition, asymptomatic adults at high risk for other reasons (i.e., family history) may also have their exams coded as diagnostic even though the USPSFT would still consider such an exam to be a screening service, as noted below.

In the case of women at higher risk for breast cancer, a mammography examination may be more extensive, involving more images than would be taken for an average risk woman. This more intensive procedure is traditionally coded as a “diagnostic” mammogram instead of a “screening” mammogram, even though the patient is asymptomatic and her screening is scheduled at regular intervals. State Consumer Assistance Programs report receiving complaints from women who are at increased risk for breast cancer and who have faced unexpected cost-sharing for annual mammograms.

Adults at increased risk for colorectal cancer have complained that insurers unexpectedly imposed cost-sharing for their regular screening colonoscopies. This was true even though the surveillance colonoscopy is the same procedure that would be performed on an average-risk adult. As is the case with polyp removal, coding practices vary for colonoscopies conducted for adults at higher risk. Insurers may or may not require special coding practices to indicate that the colonoscopy was performed as a screening or preventive measure on an asymptomatic individual who is at increased risk for colorectal cancer.

USPSTF recommendations – The USPSTF recommendations for colorectal cancer screening focus primarily on its use among the general population at average risk for developing the disease.

USPSTF recommendations also make mention of subpopulations who are at higher risk for colorectal cancer because of their family or personal history. Regarding family history, the USPSTF writes, “The recommendations do apply to those with first-degree relatives who have had colorectal adenomas or cancer, although for those with first-degree relatives who developed cancer at a younger age or those with multiple affected first-degree relatives, an earlier start to screening may be reasonable.”21

For individuals with a personal history of colon polyps, the recommendations state, “When the screening test results in the diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable.” Though it does not elaborate, the statement does not seem to suggest that patients with such personal history should not receive regular screening exams, rather that such patients may require different screening regimens compared to the average risk population.

The USPSTF recommendations also do not elaborate on what is considered to be “clinically significant colorectal adenomas or cancer,” although the criteria are well described in the literature. Surveillance guidelines issued by the ACS/MSTF go into greater detail about what is and is not clinically significant, (see box) and conclude that surveillance regimens are screening regimens since the patient is asymptomatic.22,23,24

ACS/MSTF Colorectal Cancer Surveillance Guidelines

  1. Patients with small rectal hyperplastic polyps should be considered to have normal colonoscopies, and therefore the interval before the subsequent colonoscopy should be 10 years. An exception is patients with a hyperplastic polyposis syndrome.     They are at increased risk for adenomas and colorectal cancer and need to be identified for more intensive follow up.
  2. Patients with only one or two small (<1cm) tubular adenomas with only low-grade dysplasia should have their next follow-up colonoscopy in 5 to 10 years. The precise timing within this interval should be based on other clinical factors (such as prior colonoscopy findings, family history, and the preferences of the patient and judgment of the physician.)
  3. Patients with 3 to 10 adenomas, or any adenoma >1 cm, or any adenoma with villous features, or high-grade dysplasia should have their next follow-up colonoscopy in 3 years providing that piecemeal removal has not been done and the adenoma(s) are completely removed. If the follow-up colonoscopy is normal or shows only one or two small tubular adenomas with low-grade dysplasia, then the interval for the subsequent examination should be 5 years.
  4. Patients who have more than 10 adenomas at one examination should be examined at a shorter (<3 years) interval established by clinical judgment, and the clinician should consider the possibility of an underlying familial syndrome.
  5. Patients with sessile adenomas that are removed piecemeal should be considered for follow up at short intervals (2 to 6 months) to verify complete removal.     Once complete removal has been established, subsequent surveillance needs to be individualized based on the endoscopist’s judgment. Completeness of removal should be based on both endoscopic and pathologic assessments.
  6. More intensive surveillance is indicated when the family history may indicate hereditary nonpolyposis colorectal cancer.

Insurer payment practices vary –  Among the insurers interviewed, one always imposes cost-sharing for colonoscopy screening of high-risk adults when it is performed prior to age 50 or more frequently than every 10 years; three never impose cost-sharing; and two impose cost-sharing based on how the provider codes the procedure. One insurer waives cost-sharing for the initial screening colonoscopy for a high-risk adult, even if it takes place prior to age 50, but not for subsequent screens ordered more frequently than every 10 years.

The medical director for one plan that does not impose cost-sharing noted that screening is particularly important for individuals at an increased risk. In contrast, medical directors for the plans that impose cost-sharing described surveillance colonoscopies as “diagnostic.” One explained that the procedure is diagnostic because it is the result of a prior history of colorectal cancer and because the increased frequency of screening, such as 5 years, falls outside of the USPSTF recommendations.

Another medical director complained that the USPSTF guidelines are “gray” and leave much to be interpreted by insurers in making coverage and cost-sharing determinations. He suggested that cost-sharing determinations are also problematic for other preventive services provided to asymptomatic adults, such as mammography screening for breast cancer, and concluded that “colonoscopy is not going to be the only issue.” At the same time, he acknowledged that his insurer’s claims system does not track time intervals between colonoscopies, so depending on how the doctor codes the procedure, a patient at increased risk who receives more frequent colonoscopy screening might still avoid cost-sharing.

Insurer Payment Practices for Screening Colonoscopy in High-Risk Individuals
State/Insurer Insurer Imposes Cost-sharing?
New Mexico
Insurer A No
Insurer B No
Insurer C Yes if screened more frequently than every 10 years
Insurer D No
Insurer E Depends on provider coding
Insurer F Yes
Insurer G Depends on provider coding

Screening Colonoscopy, Cost-Sharing, and Regulatory Guidance: Observations from the States

State officials are generally aware of consumer confusion and unexpected cost-sharing as a result of consumer complaints related to screening colonoscopies. The Connecticut Office of the HealthCare Advocate and the North Carolina Health Insurance Smart NC, both Consumer Assistance Program (CAP) grantees, said that cost-sharing for a screening colonoscopy has generated more consumer complaints than any of the ACA’s new consumer protections. Yet, in other states, such as South Carolina, insurance regulators have heard few, if any, complaints.25

A handful of state legislatures have considered new legislation addressing the issue of cost-sharing for screening colonoscopy to clarify when cost-sharing must be waived in one or more of these clinical circumstances.  Recently, in response to consumer complaints, Connecticut passed a law to prohibit health insurers from imposing a deductible for colonoscopy that was initially undertaken as a screening procedure.26 The Connecticut law becomes effective in January 2013 and will apply to all insurance policies (including grandfathered policies) but will not reach self-insured group health plans27 which are not regulated by states. The Connecticut law also does not specify that other forms of cost-sharing, such as coinsurance, must be waived.  Similar legislation was introduced in Vermont to clarify that cost-sharing should be waived for screening colonoscopy when recommended for high-risk patients, when colon polyps are removed, and in other circumstances, but this bill did not advance.28 In Virginia, legislation also was introduced, but did not pass, that prohibited cost-sharing on any diagnostic service performed as a result or in conjunction with an ACA mandated preventive service, such as polyp removal during a screening colonoscopy or a biopsy performed as follow up to a screening mammogram.29

Several years prior to the ACA, Maine passed a law to require health care providers to bill an insurer for a screening colonoscopy as the primary procedure even if a polyp is removed when the provider recommends the colonoscopy as a screening test.30  The Maine law only applies to fully insured health plans, not self-insured employer-sponsored plans, and only addresses polyp removal, not the two other clinical scenarios described earlier in the paper, where unexpected cost-sharing can arise.

Beyond legislation, guidance might also be provided by state insurance regulators. So far, however, no state regulators have taken formal steps to clarify how health insurance claims for screening colonoscopy should be submitted or covered under the ACA. Some state regulators expressed concern they do not have the clinical expertise to intervene in provider coding practices which underlie many of the issues related to cost-sharing by consumers. CAP staff who help consumers appeal denied health insurance claims suggest that inconsistent coding by providers reinforces inconsistency in coverage. For example, CAP staff in North Carolina reported less success in reducing cost-sharing for a consumer when a provider codes a screening colonoscopy as diagnostic.

State regulators in Oregon have encouraged insurers to take a more proactive role educating their providers on how to code screening colonoscopy. The Department hopes insurers and providers will work collaboratively so that providers would use a coding modifier to indicate screening colonoscopy. Regulators continue to monitor this issue.

In general, state regulators appear to be looking to the federal government for direction. In Georgia, for example, regulators said they are awaiting further guidance in order to move ahead on this issue. Other state regulators and CAP staff also indicated they have reached out to HHS for further guidance and do not want to “get ahead of HHS” on this matter.   When asked how to resolve this issue, one regulator suggested that a clearer definition of screening, specifically in the context of the three circumstances described above, would be helpful and could prompt insurers to provide clear, consistent guidance about coding.

To date, the federal government has not issued guidance on how insurers should define “screening” colonoscopy for purposes of eliminating cost-sharing under the ACA. In a different context and prior to the ACA, the Internal Revenue Service (IRS) issued guidance regarding the coverage of preventive services in tax-preferred high-deductible health plans with health savings accounts (HSA-eligible HDHPs). In 2004 the IRS specified that screening colonoscopy was a preventive service eligible for first-dollar coverage under these plans and specifically noted that the “removal of polyps during a diagnostic colonoscopy is preventive care.”31 By contrast, Medicare waives cost-sharing for screening colonoscopy, although Medicare payment rules specify that coinsurance will apply when removal of polyps occurs during the procedure. Legislation has been introduced in Congress to change this practice.32

Introduction Methodology

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