August 10, 2009 | Debbie Mackaman | Comments 0
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CMS announces a coverage determination on the “screening virtual colonoscopy”

On August 7, CMS issued transmittal R105NCD to implement its decision to maintain non-coverage of computed tomography colonography (CTC) for colorectal cancer screening, also known as a “virtual colonoscopy.” In 2008, the medical community had recommended that CMS consider coverage of this exam for screening purposes in specific individuals. After performing its own review, CMS has determined that the current medical evidence is inadequate and that no national coverage determination (NCD) is appropriate at this time.

Currently, Medicare beneficiaries can receive one of the following colorectal cancer screening tests:

  • Fecal occult blood test (guaiac-based or immunoassay-based) once every 12 months;
  • Flexible sigmoidoscopy once every 4 years depending on risk factors;
  • Screening colonoscopy once every 10 years for patients without a known risk;
  • Screening colonoscopy once every 2 years for patients at high risk for colorectal cancer;
  • Barium enema every 4 years as a substitute for a flexible sigmoidoscopy;
  • Barium enema every 2 years as a substitute for a screening colonoscopy for high risk patients.

Since CMS has determined that screening CTCs are non-covered for dates of service on and after May 12, 2009, a signed ABN is not required to be able to bill the patient for the service. However, under the revised ABN instructions, it can be used to inform the patient in advance of their financial responsibility.

More information on covered colorectal cancer screening services can be found in the Medicare Claims Processing Manual, Chapter 18, and the Medicare Benefit Policy Manual, Chapter 1.

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Debbie Mackaman About the Author:

Debbie is an instructor for HCPro’s Medicare Boot Camp®—Hospital Version. She has over 18 years of experience in the healthcare industry, including both inpatient and outpatient Prospective Payment Systems (IPPS, OPPS) and Critical Access Hospital (CAH) coding and reimbursement issues. She most recently held the position of the Compliance Officer and Director of Health Information Services for a healthcare system.

She consults with hospitals, physicians and other healthcare providers on a wide range of coding and billing issues. She assists in the development of compliance programs, with a focus on high risk areas including RAC topics, documentation improvement, coding and billing audits, and chargemaster maintenance.

She is an active participant with state and national organizations and task forces on coding and payment policies, privacy and continuing education. She is accredited as a Registered Health Information Administrator (RHIA) and a Certified Healthcare Compliance Officer (CHCO). She is a member of the American Health Information Management Association (AHIMA) and is the past president of the Montana Health Information Management Association (MHIMA).

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