Patient cost sharing for screening colonoscopy

AGA position: AGA urges correction of Medicare beneficiary cost sharing for screening colonoscopy.

Passage of the Affordable Care Act (ACA) marked a major victory in the fight against cancer. The law waives the coinsurance and deductible for many cancer screening tests,1 including colonoscopy, sigmoidoscopy, fecal immunochemical test
(FIT) and fecal occult blood testing (FOBT), which screen for colorectal cancer. However, due to the unique nature of colonoscopy, many patients wind up paying out of pocket. AGA urges Congress to correct this “cost sharing” problem.


Colonoscopy is a unique screening test because gastroenterologists are able to remove precancerous polyps and small cancers during the screening procedure. Under Medicare coding rules, removal of any polyp reclassifies the screening
as a therapeutic procedure for which patients must pay coinsurance. This means a patient can go to the gastroenterologist for a colonoscopy assuming it’s free, only to receive a bill for the coinsurance after the doctor finds and removes a suspicious polyp.

The Obama administration issued a set of FAQs on the implementation of preventive benefits to the ACA that clarified that private insurers cannot impose cost sharing for a screening colonoscopy that turns therapeutic since polyp
removal is “an integral part of a colonoscopy.” AGA strongly supported this guidance and continues to advocate for this policy change in Medicare.

Is your colonoscopy covered? Read this patient resource and find out what you can expect to pay.


CMS stated in the 2011 Medicare physician fee schedule final rule that legislative action is necessary to waive the beneficiary coinsurance for colorectal cancer screenings that become therapeutic during the same clinical encounter.

AGA urges Congress to correct this “cost sharing” problem for Medicare patients. The Removing Barriers to Colorectal Cancer Screening Act, legislation introduced in the House as H.R. 1570 by Reps. Donald Payne, Jr., D-NJ, and David McKinley, R-WV, and in the Senate as S.688 by Sens. Sherrod Brown, D-OH, Susan Collins, R-ME, Ben Cardin, D-MD, and Roger Wicker, R-MS, would correct this cost sharing problem for Medicare patients by waiving the coinsurance for a screening colonoscopy regardless of the outcome.


Cost sharing creates financial barriers, which discourages the use of recommended preventive services. This could have a major impact on colorectal cancer screening since more than one third of U.S. adults age 50 and older have never been screened.

Bottom line: Screening colonoscopy is the most cost effective test for preventionof colorectal cancer. Patients should be incentivized, through the elimination of cost sharing, to use colonoscopy as a colorectal cancer screening mechanism. Additionally, the preventive screening benefit has contributed to the decline in
colorectal cancer rates in our country and this benefit should be preserved in any health care reform legislation.

ColonoscopyEffective January 2011
Screening that becomes therapeutic
20% of the Medicare-approved amount with no Part B deductible. If the test is done in a hospital
outpatient department or surgical center, 25% of the Medicareapproved amount.

1. Sec. 4104 of the “Patient Protection and Affordable Care Act” (ACA) waives the beneficiary coinsurance and deductible for covered preventive services that have a grade “A” or “B” from the U.S. Preventive Services Task Force (USPSTF). Colonoscopy, sigmoidoscopy and fecal occult blood testing (FOBT) have all been assigned an “A” rating from the USPSTF for adults beginning at age 50 and continuing until age 75.

Sec. 4104 also requires, effective Jan. 1, 2011, the deductible for colorectal cancer screenings be waived for Medicare beneficiaries regardless of the code that is billed for the establishment of a diagnosis as a result of the test, or for the removal of tissue or other matter or other procedure that is furnished in connection with, as a result of, and in the same clinical encounter as a screening test.