Colorectal Cancer's Costs Explained
Summary:
On September 29, 2022, MLN released a retro-dated change in Copays related to colorectal procedures to a diagnostic colonoscopy or sigmoidoscopy. This becomes retroactive as of January 1, 2022, but the reductions will not affect providers until 2023. We look at how US Healthcare as well as providers and patients are impacted by the growing need for preventative care in both physical and financial perspectives.
Definitions relating Colon Cancer and Colon Cancer Costs
A colonoscopy is a diagnostic procedure used to examine the inside of the large intestine and rectum. A thin, flexible tube with a light and camera at one end is inserted into the rectum. Images are transmitted to a video monitor, allowing the doctor to look for abnormalities, such as polyps or cancer.
A sigmoidoscopy is a diagnostic procedure used to examine the interior of the sigmoid colon and rectum. A sigmoidoscope, a thin, tube-like instrument with a light and lens at one end, is inserted into the rectum.
The billing codes for colonoscopy are; CPT 48800 (diagnostic colonoscopy) and CPT 48900 (sigmoidoscopy). The modifiers used for CPT 48800 are 52 (Colonoscopy, diagnostic; limited), and 53 (Colonoscopy, diagnostic; with a collection of specimen(s)). The modifiers used for CPT 48900 are TC (transitional care), GY (geriatric service), 26 (professional component), and 90 (incidental procedures).
Where can Colonoscopies be Performed?
Colonoscopies are performed most often in a procedure at a medical clinic or outpatient department of a hospital. The most common provider or specialist that bills for colonoscopies is a Gastroenterologist. Gastroenterologists overseas the entire digestive track from the mouth to anus. (link) From the Payer side, there should be a valid referral to the Gastroenterologist, while from the Provider side there should be a valid authorization and reason for such a procedure.
Colonoscopy Costs Explained
The cost for colonoscopies ranges from payer to payer and state to state, but recent numbers point to a colonoscopy screening total costs ranging from $2,010 to $3,764 (link). Medicare pays for a colonoscopy screening test, but the amount Medicare covers are based on whether the patient has low or high risk of colorectal cancer. If symptoms or circumstances appear that the patient is at high risk for colorectal cancer, Medicare will pay 80% for a diagnostic colonoscopy. The average copay a patient will pay is $119 for Ambulatory Surgical Centers (ASC) and $199 for Hospital Outpatient Departments (link) but if the Patient has a Medicare Advantage this amount could be far less or around this amount. (link) Patients should be aware that many Medicare Advantage Plans offer FREE polyp removal as part of their coverage as well.
Colorectal Cancer has the 2nd Highest Treatment Cost in USA Healthcare
Colorectal cancer has the second highest treatment cost ranging from $40,000 to $80,000 depending on the stage (link). With over 106,000 new colorectal cancer diagnoses per year in the USA (link), that equates to $4.24 Billion to $8.48 Billion in healthcare costs. The stats don’t lie, if we can find an early diagnosis of Colorectal cancer we can save lives and possibly $2-$5 Billion in healthcare-related costs for Colorectal Cancer treatment.
Why Gastroenterologists are so vital in Early Detection and Cost Containment
Non-Gastroenterologists are 5 times more likely to miss colorectal cancer than a Gastroenterologist. (link) They are experts on the digestive tract as well as the tools needed to perform preventative screenings, identify and diagnosis colorectal cancer, the treatment options available based on the stage of the cancer, as well as proper training of all tools needed to perform surgeries needed.
Proper Provider Documentation of a Colonscopy
During the procedure it should have stated the patient was sedated, the usage of a flexible tube with a camera and light was used to examine the rectum and inside the full length of the colon. If anything suspicious was found the Doctor would order a biopsy, and if polyps were present that they were successfully removed with or without physical scarring. This will help substantiate approval and full reimbursement/payment. (link)
SUMMARY:
Colonoscopies are an amazing preventative measure to identify colon cancer at earlier stages. While both Medicare and Medicare Advantage are dedicated to helping patients, the financial savings to patients and payers for preventative and early detection of colorectal cancer could help save Healthcare from $2-$5 Billion in annual costs. It is vital that patients, primary care providers, gastroenterologists, and payers all come together to find early detection, proper treatment, and with it patient lives will improve and the 2nd highest cost to healthcare can be contained.
