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Colorectal Cancer Screening

Overview

Colorectal Cancer Screening

Colorectal cancer is the second leading cause of cancer deaths in the United States.  Approximately 56,290 people will die from colorectal cancer, and 145,290 people will be newly diagnosed with the disease in 2005.  

Colorectal cancer is usually found in people ages 50 and older.  The U.S. Preventive Services Task Force recommends screening for colorectal cancer for people ages 50 and older. Colorectal cancer can be prevented and treated through routine screening and early detection.

What Medicare Covers

Medicare covers various screening tests to help find colorectal cancer itself or identify and remove precancerous polyps (growths in the colon).  Coverage for these tests varies based on a beneficiary's risk for colorectal cancer.  A beneficiary is considered to be at high risk if he or she has any of the following risk factors:

  • A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp (a type of polyp that could become cancerous);
  • A family history of familial adenomatous polyposis (this involves multiple adenomatous polyps, often in the hundreds, and carries a very high risk of colon cancer);
  • A family history of hereditary nonpolyposis colorectal cancer (a type of colorectal cancer that runs in families and tends to cause cancer at a relatively young age - under 45 years);
  • A personal history of adenomatous polyps;
  • A personal history of colorectal cancer;
  • A personal history of inflammatory bowel disease, including Crohn's Disease and ulcerative colitis.

Colorectal cancer screening tests and procedures can be used alone or in various combinations and include the following:

  • Fecal occult blood test (FOBT) - This test checks for occult or hidden blood in the stool.  A health care provider gives a fecal occult blood test card to the beneficiary, who takes it home and places stool samples on it.  The beneficiary either returns the card with the stool samples to the health care provider or to a laboratory for testing.  Medicare covers one screening FOBT annually for beneficiaries aged 50 and older.  A written order from the physician responsible for using the results of the test in the management of the beneficiary's medical condition is required for Medicare coverage of this test. The deductible and coinsurance do not apply to this test.
  • Flexible sigmoidoscopy - In this procedure, the provider inserts a short, thin, flexible, lighted tube into the rectum to check for polyps or cancer in the rectum and lower third of the colon.  A beneficiary may also receive a fecal occult blood test in combination with this procedure.  For beneficiaries at high risk for colorectal cancer, Medicare covers 1 screening flexible sigmoidoscopy every 4 years.  For beneficiaries ages 50 and older not at high risk for colorectal cancer, Medicare also covers 1 flexible sigmoidoscopy every 4 years.  However, if a beneficiary who is not at high risk has had a colonoscopy in the preceeding 10 years, then Medicare will not pay for a screening flexible sigmoidoscopy until 119 months have passed from this last colonoscopy.  A doctor of medicine or osteopathy must order this screening test.  As of January 1, 2007, the Medicare Part B deductible has been waived for colorectal cancer screening tests.  However, if a screening test results in the biopsy or removal of a lesion or growth, the procedure is considered diagnostic, and the Medicare Part B deductible applies.  For screenings performed in an outpatient hospital department or ambulatory surgical center, the beneficiary is responsible for 25% of the Medicare approved amount.
  • Colonoscopy - In this procedure, the provider inserts a longer, thin, flexible, lighted tube into the rectum to check for polyps or cancer in the rectum and the entire colon.  Most polyps and some cancers can be found and removed during this procedure, which is considered the "gold standard" test for colorectal cancer screening.  Medicare provides coverage for 1 colonoscopy every 2 years for high risk beneficiaries regardless of age. Medicare covers 1 colonoscopy every 10 years for beneficiaries not at high risk, but not within 47 months of a screening flexible sigmoidoscopy.  A doctor of medicine or osteopathy must order this screening test.  As of January 1, 2007, the Medicare Part B deductible has been waived for colorectal cancer screening tests.  However, if a screening test results in a biopsy or removal of a lesion or growth, the procedure is considered diagnostic, and the Medicare Part B deductible applies.  For screenings performed in an outpatient hospital department or ambulatory surgical center, the beneficiary is responsible for 25% of the Medicare approved amount.  Beneficiaries are not liable for the costs of this procedure when performed at a critical access hospital.
  • Barium enema - In this procedure, the beneficiary is given an enema with barium.  X-rays are taken of the colon, which allow the provider to see the outline of the colon and to check for polyps or other abnormalities.  Medicare covers this screening test as an alternative to a flexible sigmoidoscopy, or a high risk screening colonoscopy.  For beneficiaries at high risk for colorectal cancer, Medicare covers 1 screening barium enema procedure every 2 years, regardless of age.  For beneficiaries not considered high risk and who are ages 50 and older, Medicare covers 1 screening barium enema procedure every 4 years.  A doctor of medicine or osteopathy must order this screening test in writing and justify why this test is an appropriate alternative for the beneficiary.  As of January 1, 2007, the Medicare Part B deductible has been waived for colorectal cancer screening tests.  However, if a screening test results in the biopsy or removal of a lesion or growth, the procedure is considered diagnostic, and the Medicare Part B deductible applies.  For screenings performed in an outpatient hospital department or ambulatory surgical center, the beneficiary is responsible for 25% of the Medicare approved amount.  Beneficiaries are not liable for the costs of this procedure when performed at a critical access hospital.

Other Helpful Information

Medicare has covered colorectal cancer screening tests and procedures since 1998, but use of this benefit has been low.  Medicare claims from 1998 - 2004 indicate that only about 52% of beneficiaries have had at least one claim for a colorectal cancer test during this window.  There is clearly an opportunity to improve colorectal cancer screening rates in the Medicare population.

This section provides information, resources, and tools to support providers, organizations that communicate with beneficiaries, and researchers in the delivery, promotion, and tracking of colorectal cancer screening tests.

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Related Links Inside CMS
Quick Reference Information:  Medicare Preventive Services

Medicare.gov Colorectal Cancer Screening Information

Related Links Outside CMSExternal Linking Policy

U.S. Preventive Services Task Force Recommendation

NCI Cancer Screening Fact Sheet

ACS Colorectal Cancer Facts and Figures 2008-2010

CDC Colorectal Cancer Information

 

Page Last Modified: 12/23/2008 1:32:20 PM
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