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Age for reimbursed colorectal cancer screening studies now begin at age 45

In the May 18 issue of the Journal of the American Medical Association, the U.S. Preventive Services Task Force (USPSTF) published updated guidelines for Screening for Colorectal Cancer. In a major move, the USPSTF has lowered the age for when adults should start screening for colon and rectal cancer from 50 to 45. Because coverage from Medicare and private payers follow USPSTF guidelines, more individuals in this lowered age bracket can be expected to receive these life-saving exams.

The USPSTF guidelines include direct visualization tests to screen for colorectal cancer, specifically colonoscopy, CT colonography, and flexible sigmoidoscopy.   

The Patient Protection and Affordable Care Act (ACA) authorized CMS to modify the coverage of any Medicare-covered preventive service in place to make the coverage consistent with USPSTF recommendations. So these new colon cancer screening guidelines should increase reimbursable services to a new group of Medicare beneficiaries, and private payers will follow suit. 

Medicare coverage is especially pertinent to colorectal cancer screening services. For example, Medicare will make full 100 percent allowable payment for the screening colonoscopy service— which is set at the same amount paid for a diagnostic colonoscopy even if the gastroenterologist detects and removes a polyp during the screening procedure. Thus, the Medicare beneficiary is not responsible for 20 percent of the full payment amount for a diagnostic colonoscopy. Even when a gastroenterologist performs extra work by removing polyps that are detected during the procedure, the beneficiary does not incur the co-payment charge.

The USPSTF is an independent, volunteer panel of national experts who work in the fields of prevention and evidence-based medicine. The Task Force works to improve the health of people nationwide by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, and preventive medications. All recommendations are published on the Task Force’s Web site and/or in a peer-reviewed journal.

Colorectal cancer is the third leading cause of cancer death among adults, with more than 52,000 people in the U.S projected to die from the disease in 2021. While most colorectal cancer cases are diagnosed in people aged 65 to 74, incidents among adults aged 40 to 49 have increased by nearly 15% between 2000 and 2016. Meanwhile, 10.5% of new colorectal cancer cases occur in those younger than age 50.

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health care & life sciences, medicare, cms

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