Colorectal Cancer Screening

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[1] 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[2] 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).

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Michael S. Pieciak, Commissioner

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Date

Appendix A: ICD 10-CM Diagnosis Codes for CRC Screening

ICD-10 Code

Description

D12.0

Benign neoplasm of cecum

D12.2

Benign neoplasm of ascending colon

D12.3

Benign neoplasm of transverse colon

D12.4

Benign neoplasm of descending colon

D12.5

Benign neoplasm of sigmoid colon

D12.6

Benign neoplasm of colon, unspecified

D12.7

Benign neoplasm of rectosigmoid junction

D12.8

Benign neoplasm of rectum

D12.9

Benign neoplasm of anus and anal canal

D50.9

Iron deficiency anemia, unspecified

K63.5

Polyp of colon

Z00.00

Encounter for general adult medical examination without abnormal findings

Z00.01

Encounter for general adult medical examination with abnormal findings

Z12.10

Encounter for screening for malignant neoplasm of intestinal tract, unspecified

Z12.11

Encounter for screening for malignant neoplasm of colon

Z12.12

Encounter for screening for malignant neoplasm of rectum

Z12.13

Encounter for screening for malignant neoplasm of small intestine

Z13.811

Encounter for screening for lower gastrointestinal disorder

Z80.0

Family history of malignant neoplasm of digestive organs

Z80.9

Family history of malignant neoplasm, unspecified

Z83.71

Family history of colonic polyps

Z85.030

Personal history of malignant carcinoid tumor of large intestine

Z85.038

Personal history of other malignant neoplasm of large intestine

Z85.040

Personal history of malignant carcinoid tumor of rectum

Z85.048

Personal history of other malignant neoplasm of rectum, rectosigmoid junction, and anus

Z85.060

Personal history of malignant carcinoid tumor of small intestine

Z85.068

Personal history of other malignant neoplasm of small intestine

Z86.010

Personal history of colonic polyps

Z86.018

Personal history of other benign neoplasm

Z87.19

Personal history of other diseases of the digestive system

[1] 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).

[2] The World Health Organization. (2019). International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).