Jun 2001 Table of Contents

GETTING PAID

Medicare Expands Preventive Screening Benefits



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On July 1, new rules take effect that cover colorectal screening for more patients as well as more frequent Pap smears and pelvic exams.

Fam Pract Manag. 2001 Jun;8(6):16.

As a result of legislation signed into law last December, Medicare coverage of screening tests will soon be expanded. Beginning July 1, more of your patients may be eligible for screening, and others may be eligible to be screened more often. Of course, more screening isn’t necessarily better, but when certain types of screening are indicated and Medicare’s criteria are met, Medicare will reimburse you for the services. Here’s what you need to know.

Colorectal screening

Medicare’s colorectal screening benefit will cover colonoscopies for Medicare beneficiaries who aren’t at high risk for developing colorectal cancer. Previously, screening colonoscopies were limited to individuals at high risk. Under the new rules, a screening colonoscopy for beneficiaries who don’t meet the criteria for high risk will be covered once every 10 years unless the beneficiary has had a screening flexible sigmoidoscopy within the past four years.

You will need to use code G0121 for this service. You should continue using the existing code, G0105, for screening colonoscopies done for individuals at high risk. Both G0121 and G0105 are paid at the same rate as diagnostic colonoscopy (code 45378).

On a related point, Medicare will cover a screening flexible sigmoidoscopy (G0104) for beneficiaries 50 and older once every four years unless the beneficiary is at low risk for developing colorectal cancer and has had a screening colonoscopy within the last 10 years. In that case, Medicare will cover a screening flexible sigmoidoscopy only after the 10 years have passed.

Medicare considers an individual at high risk for colorectal cancer if he or she has one or more of the following:

  • A close relative (e.g., sibling, parent or child) who has had colorectal cancer or an adenomatous polyp,

  • A family history of adenomatous polyposis,

  • A family history of hereditary nonpolyposis colorectal cancer,

  • A personal history of adenomatous polyps,

  • A personal history of colorectal cancer,

  • Inflammatory bowel disease, including Crohn’s disease, and ulcerative colitis.

Pap smears and pelvic exams

The new rules will cover screening Pap smears and screening pelvic exams for qualified beneficiaries every two years. Previously, these exams were covered every three years.

Patients may still be eligible for more frequent (i.e., annual) screening exams if they are considered to be at high risk for vaginal or cervical cancer or are of childbearing age and have had an exam indicating the presence of cervical or vaginal cancer or other abnormality during any of the preceding three years.

Medicare considers prenatal exposure to diethyl-stilbestrol as a high risk for developing vaginal cancer. For cervical cancer, the Medicare factors for high risk are as follows:

  • Early onset of sexual activity (under 16 years of age),

  • Multiple sexual partners (five or more in a lifetime),

  • History of a sexually transmitted disease (including HIV),

  • Fewer than three normal Pap smears or no Pap smears within the previous seven years.

For collection of the Pap smear, you should continue to use HCPCS code Q0091, “Screening Pap smear, obtaining, preparing and conveyance of cervical or vaginal smear to laboratory.” To report the screening pelvic and breast exam, use code G0101, “Cervical or vaginal cancer screening, pelvic and clinical breast examination.” Both of these services are payable under the Medicare physician fee schedule, and neither is subject to the Medicare Part-B deductible. Note that you can be paid for a separately identifiable evaluation and management service and Q0091 or G0101 on the same date of service, but you must use a -25 modifier in this situation.

Kent Moore is the AAFP’s manager for health care financing and delivery systems and is a contributing editor to FPM. Conflicts of interest: none reported.

Copyright © 2001 by the American Academy of Family Physicians.
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