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Insurance Bulletin No. 207
Colorectal Cancer Screening
January 8, 2020
The purpose of this bulletin is to clarify the procedures covered by Vermont’s colorectal cancer (CRC) screening mandate, 8 V.S.A. § 4100g. The mandate applies to all health insurers that provide comprehensive health care coverage, including non-profit hospital and medical service corporations, health maintenance organizations, association health plans (whether fully-insured or self-insured) and multiple employer welfare arrangements.
Under the statute, insurers are required to provide coverage for CRC screening without any co-payment, deductible, coinsurance, or other cost-sharing requirement. Id. § 4100g(d). Services associated with CRC screening, including tissue removal, laboratory services, physician services, facility use, and anesthesia are also required to be covered without cost-sharing. Id. § 4100g(d)(1)-(5).
For insureds over age 50, the benefit includes annual fecal occult blood testing plus one flexible sigmoidoscopy every five years, or one colonoscopy every 10 years. Id. § 4100g(b)(1). For insureds who are at high risk of CRC, the benefit includes CRC screenings, examinations, and laboratory tests as recommended by the insured’s treating physician. Id. § 4100g(b)(2). An insured is at high risk of CRC if he or she has: 1) family medical history of CRC or genetic predisposition to CRC; 2) a prior occurrence of CRC or precursor polyps; 3) a prior occurrence of a chronic digestive disease (such as Crohn’s disease or ulcerative colitis); or 4) other predisposing factors determined by their physician. Id. § 4100g(c)(1)-(4).
In order to ensure consistent application of the mandate between insurers, claims for CRC screening and associated services shall process without member cost-sharing when the claim reflects an appropriate screening diagnosis as the reason for the procedure(s). A list of appropriate screening diagnoses is attached in Appendix A: ICD 10-CM Diagnosis Codes for CRC Screening. The claim may contain other diagnoses but the presence or absence of any other diagnosis on the claim, including in the primary diagnosis position, shall not prevent coverage without cost-sharing as required by § 4100g(d). If subsequent screening is medically necessary because a prior study was inconclusive, such claims shall also process without member cost-sharing.
The American Medical Association publishes quarterly updates to codes and the above-referenced codes may change, be retired, or be replaced.
The Department encourages communication between insurers and their contracted providers to encourage standard coding practice and coding instructions. Increased collaboration encourages compliance, helps to produce better health outcomes for Vermonters, and provides efficiencies for insurers and their contracted providers.
Inquiries about this Bulletin should be directed to Emily Brown, Director of Rates and Forms (Emily.Brown@vermont.gov).
Michael S. Pieciak, Commissioner
Appendix A: ICD 10-CM Diagnosis Codes for CRC Screening
Benign neoplasm of cecum
Benign neoplasm of ascending colon
Benign neoplasm of transverse colon
Benign neoplasm of descending colon
Benign neoplasm of sigmoid colon
Benign neoplasm of colon, unspecified
Benign neoplasm of rectosigmoid junction
Benign neoplasm of rectum
Benign neoplasm of anus and anal canal
Iron deficiency anemia, unspecified
Polyp of colon
Encounter for general adult medical examination without abnormal findings
Encounter for general adult medical examination with abnormal findings
Encounter for screening for malignant neoplasm of intestinal tract, unspecified
Encounter for screening for malignant neoplasm of colon
Encounter for screening for malignant neoplasm of rectum
Encounter for screening for malignant neoplasm of small intestine
Encounter for screening for lower gastrointestinal disorder
Family history of malignant neoplasm of digestive organs
Family history of malignant neoplasm, unspecified
Family history of colonic polyps
Personal history of malignant carcinoid tumor of large intestine
Personal history of other malignant neoplasm of large intestine
Personal history of malignant carcinoid tumor of rectum
Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus
Personal history of malignant carcinoid tumor of small intestine
Personal history of other malignant neoplasm of small intestine
Personal history of colonic polyps
Personal history of other benign neoplasm
Personal history of other diseases of the digestive system
 Colonoscopy is defined as “a procedure that enables a physician to examine visually the inside of a patient's entire colon and includes the concurrent removal of polyps or biopsy, or both.” 8 V.S.A. § 4100g(a).
 The World Health Organization. (2019). International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).