Virtual Colonoscopy / CTC Reimbursement

CMS/Medicare's decision not to reimburse for Screening CT Colonography has overshadowed some very important developments regarding CTC coverage. Perhaps the biggest development is that many Private health insurance carriers are beginning to cover CTC for screening. In November 2008 Blue Cross/Blue Shield released their TEC report in favor of covering CTC for Colorectal cancer screening citing the Viatronix V3D Colon as an FDA approved screening tool in detecting colon cancer. Currently there are several BCBS regional offices reimbursing CTC. Aetna has establishing a CTC program based on the TEC report. Cigna has provided guidelines for the reimbursement of CTC screening for their millions of insured patients. Additionally, United and Oxford made the announcement to reimburse for several of their plans.

Many States are moving forward as well. In the states of Delaware, Massachusetts and Maryland, The Insurance Administration has mandated that CTC Screening be covered by all insurance carriers doing business within the state. Presently there are three Bills before Congress and thirteen bills before individual state legislatures addressing the need for Colorectal Cancer Screening which contains CTC technology. On May 28, 2010 Rep. Danny Davis and Co-sponsors Rep Mark Kirk and Rep. Dan Boren, introduced the Virtual Screening for Colorectal Cancer Act of 2010 (H.R. 5461) into the U.S. House of Representatives.

With more than 2/3rds of the eligible screening population covered by private health insurance carriers, large scale screening programs can be implemented. In Bethesda, MD where one large facility has implemented a CTC program over 5 years ago, the compliance for colon cancer screening has gone up by 70% consistently with the use of CTC. Another screening program in Madison, WI has a waiting list since achieving coverage by the local private health insurers.

One of the biggest changes has been the development of CPT I codes as of January 1, 2010. These codes now meet the needs of both Gastroenterologists and Radiologists. These will help create standard protocols for the use of CTC for screening CRC. This will be the best way to ensure rapid development of positive coverage and payment policies among all payers.

Overall, the question is, "Will you be ready when CTC is?" Adding CTC will ensure your practice is ready for the launch of this exciting new colorectal cancer screening technology which will yield your practice additional revenues and new patients.

Coverage by State:

Thanks in part to state laws mandating coverage of any colorectal cancer screening exam approved by the American Cancer Society (ACS), payors are required to cover CTC in 22 states and Washington, DC, according to a March 26 article on the American Gastroenterological Association's website.

The AGA listed the following states that are required or have agreed to provide coverage for CTC due to ACS approval:

These States have an Insurance Commissioner Mandate for coverage of CTC, if the insurance provides coverage for Colorectal Cancer Screening.

  • Alabama
  • Alaska
  • Arkansas
  • Connecticut
  • Delaware
  • District of Columbia
  • Georgia
  • Illinois
  • Indiana
  • Kentucky
  • Louisiana
  • Maine
  • Maryland
  • Missouri
  • Nevada
  • New Jersey
  • North Carolina
  • Rhode Island
  • Tennessee
  • Texas
  • Virginia
  • Wisconsin

These States have agreed to follow ACS guidelines, yet no Insurance Commissioner Mandate has been released

  • California
  • Michigan
  • Nebraska
  • New Mexico
  • New York
  • Oregon
  • Vermont
  • Washington
  • West Virginia
  • Wyoming

The ACS-mandated state coverage is bolstered by commitments from private payors to cover screening CTC for all of their insured regardless of location.

The AGA's list of insurers offering CTC as a covered benefit includes:

  • Cigna
  • CareFirst BCBS (VA, DC, MD)
  • BCBS Delaware
  • Independence Blue Cross (PA)
  • Horizon BCBS (NJ)
  • Anthem BCBS (CA, NV, CO, WI, MO, IN, KY, OH, NY, CT, VA, GA, ME, NH, NY)
  • BCBS North Carolina
  • Physicians Plus of WI
  • BCBS Rhode Island
  • BCBS Arkansas
  • United Healthcare
  • Unicare

CMS has published the Medicare Physician Fee Schedule Final Rule, including the CTC RVUs. -The document is 1,669 pages so you have to do a search for "74261" and you will find the CTC codes and their values

Here is a synopsis for CTC CPT Codes:

CPT CodePhysician Work RVU
74261 CTC diagnostic w/o contrast2.28
74262 CTC diagnostic w/ contrast 2.50
74263 CTC screening 2.28 (N=non-covered by Medicare
Compared to CT
74150 CT Abdomen w/o contrast 1.19
74160 CT Abdomen w/contrast 1.27
72192 CT Pelvis w/o contrast 1.09
72193 CT Pelvis w/contrast 1.16

So basically for 74261 and 74263 they just added CT Abd/Pel w/o contrast together (1.19 + 1.09 = 2.28) A bit more for 74262 at 2.50 (versus 1.27 + 1.16 = 2.43)

In place of the two Category III codes (0066T and 0067T) to describe Computed Tomographic Colonography (CTC), the AMA has created three Category I codes:

74261 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; without contrast material (New 1-1-2010)
74262 Computed tomographic (CT) colonography, diagnostic, including image postprocessing; with contrast material(s) including non-contrast images, if performed (New 1-1-2010)
74263Computed tomographic (CT) colonography, screening, including image postprocessing (New 1-1-2010)

A non-contrast CTC diagnostic study is of value in those patients for whom an instrument colonoscopy of the entire colon is incomplete due to an obstructing neoplasm resulting in an inability to pass the colonoscope proximally.

A contrast-enhanced diagnostic study may be useful in some patients after incomplete endoscopy to characterize indeterminate colonic masses or to better visualize colonic segments with excess fluid.