Medicare Colonoscopy Screenings - Age and frequency limit

Watch Age and Frequency Limits for Medicare Colonoscopy Screenings

Medicare benefits allow a covered screening colonoscopy once every 24 months for those patients defined as “high risk” for colorectal cancer, or once every ten years — but not within 48 months of a screening sigmoidoscopy — for those patient’s who do not qualify as “high risk.”

In addition, Medicare guidelines generally require that a screening exam is a covered benefit for those beneficiaries at low risk for colorectal cancer who are 50 years of age or older. This can vary, however, and some carriers specify medical-necessity requirements that allow low-risk beneficiaries under age 50 to receive a covered screening exam.

For beneficiaries at high risk for colorectal cancer, national Medicare policy does not set a minimum age requirement. CMS MedLearn Matters article SE0613 states, “For beneficiaries considered to be at high risk for developing colorectal cancer, Medicare covers one screening colonoscopy every two years, regardless of age.”


Turn to ABN When Exceeding Frequency Limits

On occasion, an asymptomatic patient may request a colonoscopy that does not meet Medicare screening requirements. In such cases, your best bet to collect payment is to bill the patient directly for the service.

For instance: A covered Medicare patient under the age of 50 with no apparent symptoms and low-risk factors may ask for a screening “just to be sure,” or a high-risk beneficiary who has had an exam within 18 months may request an exam for similar reasons.

To ensure that the patient understands that he will be responsible for payment, you should request that he read and sign an advance beneficiary notice (ABN). You should present the patient with the ABN well in advance of the procedure and explain to the patient why Medicare will likely deny the service.

An ABN tells the patient it’s likely that Medicare won’t cover the service, and therefore it will be the patient’s responsibility to pay. The patient can then determine whether he wants to have the procedure done.

Medicare does not mandate that you use ABNs, but it does prohibit billing a Medicare beneficiary for a denied claim unless you properly obtained a signed ABN from the patient.