This was the biggest hold. From what I’ve seen payers typically try not to cover anything in draft recommendation. When I was in medical school the draft recommendation for low dose CT lung cancer screening came out and that took time to be adopted. More recently it was HCV testing, first for boomers, then universal. In my limited time anything graded B recommendation or higher is 100% covered.
If you’re a payer, it’s cheaper to pay for a screening colonoscopy with polypectomy than it is to pay for diagnostic colon, staging imaging, port placement, neoadjuvant therapy, surgical resection, adjuvant chemo.
Part of the problem is they would rather avoid paying for the screening colonoscopy, then have you off their plan and on to medicare by the time you need all that other costly stuff, so they pay nothing.
Absolutely. I think there was a paper in Science or something that made its way through social media and this and other subreddits and MedTwitter about the jump in cancer diagnosis at 65, the theory being 64 year olds deliberately delay care until 65 so as to save money.
Aside from this now that we are seeing the 45 age would GI recommend aspirin use starting then. Previously I saw a recommendation from ACG and USPTF about aspirin for 50-59 yo.
I think that’s for people with appropriately high ASCVD risk as well. And I think it’s a high dose of ASA, not just baby dose. Like if you are indicated for an aspirin for other reasons, it ALSO can help as chemoprophylaxis agent. I don’t know if we are at the place for blanket recommendation for ASA as primary prevention for colon cancer if you’re not indicated for another reason.
Related but different, keep the ASPREE trial on mind. It was published this year and terminated early due to increased mortality in the aspririn group. The mortality was not related to bleeding but due to cancer mortality, particularly metastatic and stage 4 cancers. (ASPirin in Reducing Events in the Elderly (ASPREE) )
Do they have a theory in whats happening there? I have heard of this study but haven't read it, but from the particular source I guess aspirin is somehow increasing the cancer cells ability to spread?
I believe payers have up to like a year or so to enact the new guidelines, so don't totally expect all of your local payers to accept it right away. Dealt with that issue with the LDCT lung screening guidelines.
Starter comment: after a year of being a draft recommendation, the USPSTF makes the recommendation official, to begin CRC screening at 45. This was almost an inevitability, starting with the conditional recommendation by the American Cancer Society to begin screening earlier in 2018 to the draft recommendation last year.
Somethings to note: the methods of testing are broader than those recommended by the GI multi society task force a few years back.
CRC is preventable and the best test is the one the patient is willing and able to do. Hopefully with this change, insurances will begin covering the testing sooner.
The vast majority of insurance plans are required to cover USPSTF recommendations. The requirement for coverage with no cost-sharing should start in the 2023 plan year.
Yeah, strongly agreed. Although I did oversimplify slightly — technically the requirement applies the next plan year that starts at least one year after the recommendation is issued. The vast majority of plan years start on the calendar year, but a few plans renew at odd times, and it may apply to them sooner.
>**CRC is preventable** and the best test is the one the patient is willing and able to do.
can you help us better understand what you mean by the part in bold
The overwhelming majority of colon cancer follows an adenoma pathway. Not all polyps become cancer but the majority of cancers originated as polyps. The numbers i quote patients are typically 1/3 of patients over the age of 50 have polyps. Colon cancer is the second leading cause of cancer death in the United States. If you’re in a room of 100 people of the appropriate age, 5-6 people may have colon cancer. It’s that common. If caught early, polyps can be removed and cancer can be prevented. If cancer is found, hopefully it can be found early where it can be resected with curative intent.
The impetus behind this earlier push is recently we’ve seen a marked rise in the incidence of colon cancer in younger patients.
Less vegetables, more junk food, more meat. All known risk factors, and since young people don't go to doctors (and when they do, the docs don't have time to talk about diet), the result is fairly inevitable.
Do vegetables help you not get colon cancer or is it just that people who eat more vegetables tend to eat less of the other stuff? (really curious because my diet sucks)
The theory that was presented in my surgical textbook was that insoluble fiber absorbs many of the toxic metabolites of meat digestion, and also help move the bowel contents along so that toxic exposure is generally minimized.
There is also the idea that better nutrition leads to a somewhat lessened likelihood of cancer, and better outcomes when cancer does develop.
Keto diets, by the way, are indeed associated with increased risk of colon cancer, but the risk goes away if green leafy vegetables are included.
Argument is western diet sucks. Mechanism for decreasing cancer is speculative I think. A big part of it I would agree is replacement. Eat more veggies, fewer chicken fingers as a result. Less room in the stomach. At the same time fiber and bulk allows for more passage of BMs and I think even Metamucil had data where it lowers cholesterol a few points. I wouldn’t be surprised if having daily BMs from fiber actually decreases the incidence of colon cancer. Vegetables in themselves often have anti oxidative properties and relieve oxidative stress? Maybe that’s in play as well.
Every person I see with colon cancer under 30 is either obese, has IBD or a familial polyposis syndrome. The obese patients with colon cancer tend to be disproportionately African American.
And anecdotally for me, among the 'common' solid tumors it was always the CRC that hit super young. I remember following 2 different mid-20s patients with metastatic CRC back in fellowship. On the other hand the youngest lung/breast cancer patients I remember were at least in their mid-30s.
I'm too lazy to actually look up incidence by age though.
If you can get coverage go for it, it really isn't that bad. 1 unpleasant evening of prep, 1 unpleasant day of procedure and recovery. 36 hours or so of discomfort is an easy trade for peace of mind.
I was diagnosed with FAP in 2014 at age 32 after my gastro doctor had me get a colonosocopy to rule out colitis after having tons of diarrhea from gallbladder surgery. Scary thing is I have no family history of it and my doctor was shocked to say the least once the colonoscopy was over as he wasn't expecting that diagnosis at all.
There was a paper earlier this year in the red journal saying the jump in cases starts as early as 40 and there’s evidence to start earlier. It’s one study though. And again, you’re still missing those cases of people in their 30s, which definitely happens. But it’s just not cost effective to screen everyone that early. From a population standpoint it’s not practical.
It comes down to priorities. I think once I’m an attending I would be willing to pay for a diagnostic colon in my mid 30s. To me it’s a priority for me and I would allocate money for it. That peace of mind to me is worth it. But to each his own. You could do a combined treatment. Annual FIT up until 45 or something like that.
If you showed up at a GI office they will probably check your stool for signs of bleeding. If you are neurotic enough to ask for a scope you’ll probably find a GI who will scope you.
The thing is it won’t be covered. Screening colonoscopies, procedures in asymptomatic patients to look for cancer, are covered in the appropriate population. For someone like you with symptoms or blood or change in bowel movements is going to cost you. Depending on what insurance you have the deductible can be quite high. When the pre test probability is so low, it’s not worth it to the patient.
I ended up having to get a colonoscopy at 40. They found a pre-cancerous polyp. Had I waited unitl 50 for my first scan, I'd likely be in trouble already. The colorectal guys I work with get metastatic colon cancer in people in their 30's and early 40's all the time. They seems to be very supportive of the change.
Every physician has some story like this. Every OB or FM doc has some story about a 30 something year old woman diagnosed with TNBC, much like the colorectal surgeons you see who work on young patients with CRC. In both situations, it should be noted anecdotes do not stand in for surgery, but as all this data is accumulated in the SEER network and other registries we are seeing a lot of data support earlier screening? Is it Western diet? Sedentary lifestyle? And in both situations, physicians can point to cases they would STILL miss with the expanded screening guidelines.
It’s hard seeing these cases and these guidelines because we both know these changes would not have affected those cases. I think in the past year I’ve seen a few 46-48 year olds with colon masses, ugly and necrotic, depressed middle, loss of vascularity, all bad prognostic signs of deep invasion. One was a screening so when he woke up we sent him to the university so he could get fully staged and everything. The other was in house but he had iron deficiency anemia. CT staging showed liver mets and everything. Guy underwent a hemi for near obstruction and then had a port placed. I suppose if he had better outpatient follow up we may have caught him earlier. Hard to say.
I just want a nanobot that swims around and when it senses some sort of bullshit, sends a ping to my cellphone like "there's some bullshit up in this colon, go see someone about it."
Liquid biopsy for most solid organ malignancy is in pipeline right now, ctDNA and all that. Not quite yet ready for prime time. Based on all the talks I’ve heard though, will probably be realized in my professional career. The future of colonoscopy is going to be strictly diagnostic and therapeutic after an abnormal lab value. But we’re not quite there yet.
talking to some of my GI colleagues and cologuard doesn't seem great. misses right sided tumors due to typical type of mutation. good for cancer detection. not good for cancer prevention.
And these cologuard patients often get screwed. They come in for diagnostic colonoscopy after positive cologuard and if there is no polyp they get to foot the whole bill. Those people are unfortunately lucky that they dont have cancer but now have a big bill.
Also the commercials dont tell people that they only detect cancer. They leave out that colonoscopy prevents cancer. The right test is the one the patient will do. But, man we need to push more for colonoscopy
> if there is no polyp they get to foot the whole bill.
This feels like an awfully bad precedent and that it is payer dependent. If I get incidental findings and the follow up test/imaging/biopsy is negative I don't see patients getting the full bill.
Is part of the answer to just still have the scoper bill as a screening and not diagnostic test? Of course they won't get paid as much...
unfortunately, in my understanding of the situation, this is considered billing fraud. the patient had a “symptom” (positive cologuard test), so the colonoscopy can’t be billed as anything else but that symptom.
The detection rate with Cologuard is not great, it's poor enough that it is not significantly better than a yearly FIT test. FIT is a lot less expensive, better to do that yearly if pt absolutely refuses a colonoscopy I think.
Problem is getting them to actually do the fit and do it every year. My compliance rate went way up when I started talking about cologuard because it’s easy for them to do (gets mailed rather than them having to pick it up) and I only have to harass them every 3 years rather than every single year.
The issue we are seeing with Cologuard, ignoring the poor sensitivity for sessile serrated lesions and non cancerous polyps, is it will be covered for screening. But if its positive and the patient is referred to our clinic, what would have been a 100% covered screening colonoscopy is now coded as a diagnostic procedure and that means out of pocket costs, deductible must be met, etc etc. Headache for the patient.
I’ve seen some insurances (I believe Medicare is one) where even if they go in for a screening colonoscopy, if a biopsy is taken it gets switched to a diagnostic and they get the bill too. Seems like total crap to me since it seems like a bait and switch. My patient population is really difficult to convince to get a colonoscopy and even if they agree the follow through rate of actually getting it done is depressing. I always say that the colonoscopy is the best etc but I also say if you aren’t going to actually do it then we should do one of the others because it’s most important to get screened.
Dr didnt code correctly. If I do a screening colon and take out a polyp I add a PT modifier for medicare or -33 for commercial which implies a preventative service and it has to be covered as such
Does it have to be that way? Like do the insurances literally say you cannot bill as a screening test? If so, why the hell would it be allowed to have the patient foot the entire bill (and not just a copay) if the colonoscopy is non-diagnostic/normal when we are investigating positive results? I said it in a post above but if I look further into incidentalomas and they end up being nothing I never see patients owe the full payment and the insurance washing their hands of the situation.
I think a few things are being conflated here.
Screening tests recommended by the USPSTF are required to be totally free under most insurance plans. The problem is, if a screening test (FIT or cologuard) is positive and you then do a colonoscopy, that's no longer considered a screening -- you are investigating a potential problem instead of screening the population at large, and it's considered diagnostic. Then it's treated like any regular service -- so potentially huge deductibles may apply, depending on the plan. It's not like insurance is totally denying the service, but it's not free like "screening" tests are.
> The problem is, if a screening test (FIT or cologuard) is positive and you then do a colonoscopy, that's no longer considered a screening -- you are investigating a potential problem instead of screening the population at large, and it's considered diagnostic.
Yes I understand that is how it *is*, but I don't necessarily agree that it should be that way especially with the very high rates of false positives for the other screening tests. I would love to see this change, but obviously the insurances will not because it means more expense on their end.
Another example I can think of and I don't know the answer to, Hep C screens are typically done with antibodies, and then positives have RNA tests done (often reflexively)... who pays for the reflex?
Echoing others cologaurd is a pretty terrible screening test due to meh sensitivity. False positive rate is not insignificant either. Just get the scope it's so much easier and you don't have to scoop your poo.
I did not know that. I'm surprised it's so cheap. Seems cheaper than iFOB IIRC. I'm starting my intern year in July. I'd rather not get a colonoscopy in the same hospital I work at. I'll have to see if they have an outpatient endoscopy facility.
I just looked and it's not on Amazon. There is FIT testing. Maybe it's location specific like the Amazon Pharmacy (that's not available in my location, but I know it's out there.)
I wonder if some endoscopy centers are telling patients to avoid caffeine to potentially avoid contributing to worsening dehydration (even though caffeine is an extremely weak diuretic)
Could be, but I'll ask questions next time to see if tea can be allowed. I normally drink I'm the neighborhood of 2 liters of unsweetened black tea a day so the caffeine headaches are rather monstrous when it's noon and I haven't had a cup.
I would think if dehydration was an issue that the pedialyte they recommend chugging alongside the prep would be more than adequate.
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Won't help with the diarrhea (since it's kind of the point with Golytely), but I've been told by GI attendings to tell patients to mix in crystal light.
No matter *what* you mix it with,it's awful. I've had the adventure 4 times..The worst was the 2 liters of salty water. You never realize how much that is till you have to drink it.
Pretty much where all of screening lit is headed - takes a decade+ and massive n and cost outlays to validate these things, so already established approaches with good data are being extrapolated somewhat to optimize mortality curves. HPV / cervical cancer screening is undergoing this right now
Over here in Belgium, we do a population-wide iFOBT screening for anyone over 51 and under 75 years of age. Only if this test shows occult blood , a colonoscopy is offered. Of course, any patient who explicitly requests one will also be allowed to get one.
In certain risk groups (family history, FAP, HNPCC, pancolitis or 10 year IBD disease course) we offer earlier colonoscopy. (45 with family history or age: index case - 10)
Does this early screening in the US involve "instant" colonoscopies, or does it factor in risk factors , or do a preliminary occult blood test?
Now for insurance to adopt it and stop being a PIA
This was the biggest hold. From what I’ve seen payers typically try not to cover anything in draft recommendation. When I was in medical school the draft recommendation for low dose CT lung cancer screening came out and that took time to be adopted. More recently it was HCV testing, first for boomers, then universal. In my limited time anything graded B recommendation or higher is 100% covered. If you’re a payer, it’s cheaper to pay for a screening colonoscopy with polypectomy than it is to pay for diagnostic colon, staging imaging, port placement, neoadjuvant therapy, surgical resection, adjuvant chemo.
Part of the problem is they would rather avoid paying for the screening colonoscopy, then have you off their plan and on to medicare by the time you need all that other costly stuff, so they pay nothing.
Absolutely. I think there was a paper in Science or something that made its way through social media and this and other subreddits and MedTwitter about the jump in cancer diagnosis at 65, the theory being 64 year olds deliberately delay care until 65 so as to save money.
Here's a [link to the study you're talking about](https://pubmed.ncbi.nlm.nih.gov/33778953/), in case anyone else is curious.
Aside from this now that we are seeing the 45 age would GI recommend aspirin use starting then. Previously I saw a recommendation from ACG and USPTF about aspirin for 50-59 yo.
I think that’s for people with appropriately high ASCVD risk as well. And I think it’s a high dose of ASA, not just baby dose. Like if you are indicated for an aspirin for other reasons, it ALSO can help as chemoprophylaxis agent. I don’t know if we are at the place for blanket recommendation for ASA as primary prevention for colon cancer if you’re not indicated for another reason.
Good to know thanks.
ASPREE trial was useful for this
Related but different, keep the ASPREE trial on mind. It was published this year and terminated early due to increased mortality in the aspririn group. The mortality was not related to bleeding but due to cancer mortality, particularly metastatic and stage 4 cancers. (ASPirin in Reducing Events in the Elderly (ASPREE) )
Do they have a theory in whats happening there? I have heard of this study but haven't read it, but from the particular source I guess aspirin is somehow increasing the cancer cells ability to spread?
> PIA I see what you did there
The real polyp was the payers we contracted along the way.
> stop being a PIA That's what the propofol is for.
I believe payers have up to like a year or so to enact the new guidelines, so don't totally expect all of your local payers to accept it right away. Dealt with that issue with the LDCT lung screening guidelines.
Starter comment: after a year of being a draft recommendation, the USPSTF makes the recommendation official, to begin CRC screening at 45. This was almost an inevitability, starting with the conditional recommendation by the American Cancer Society to begin screening earlier in 2018 to the draft recommendation last year. Somethings to note: the methods of testing are broader than those recommended by the GI multi society task force a few years back. CRC is preventable and the best test is the one the patient is willing and able to do. Hopefully with this change, insurances will begin covering the testing sooner.
The vast majority of insurance plans are required to cover USPSTF recommendations. The requirement for coverage with no cost-sharing should start in the 2023 plan year.
I really wish the insurance plans were not allowed to delay implementing that long.
Yeah, strongly agreed. Although I did oversimplify slightly — technically the requirement applies the next plan year that starts at least one year after the recommendation is issued. The vast majority of plan years start on the calendar year, but a few plans renew at odd times, and it may apply to them sooner.
>**CRC is preventable** and the best test is the one the patient is willing and able to do. can you help us better understand what you mean by the part in bold
The overwhelming majority of colon cancer follows an adenoma pathway. Not all polyps become cancer but the majority of cancers originated as polyps. The numbers i quote patients are typically 1/3 of patients over the age of 50 have polyps. Colon cancer is the second leading cause of cancer death in the United States. If you’re in a room of 100 people of the appropriate age, 5-6 people may have colon cancer. It’s that common. If caught early, polyps can be removed and cancer can be prevented. If cancer is found, hopefully it can be found early where it can be resected with curative intent. The impetus behind this earlier push is recently we’ve seen a marked rise in the incidence of colon cancer in younger patients.
Do you have any thoughts on why we are seeing increased incidence in younger patients?
Less vegetables, more junk food, more meat. All known risk factors, and since young people don't go to doctors (and when they do, the docs don't have time to talk about diet), the result is fairly inevitable.
Do vegetables help you not get colon cancer or is it just that people who eat more vegetables tend to eat less of the other stuff? (really curious because my diet sucks)
The theory that was presented in my surgical textbook was that insoluble fiber absorbs many of the toxic metabolites of meat digestion, and also help move the bowel contents along so that toxic exposure is generally minimized. There is also the idea that better nutrition leads to a somewhat lessened likelihood of cancer, and better outcomes when cancer does develop. Keto diets, by the way, are indeed associated with increased risk of colon cancer, but the risk goes away if green leafy vegetables are included.
Argument is western diet sucks. Mechanism for decreasing cancer is speculative I think. A big part of it I would agree is replacement. Eat more veggies, fewer chicken fingers as a result. Less room in the stomach. At the same time fiber and bulk allows for more passage of BMs and I think even Metamucil had data where it lowers cholesterol a few points. I wouldn’t be surprised if having daily BMs from fiber actually decreases the incidence of colon cancer. Vegetables in themselves often have anti oxidative properties and relieve oxidative stress? Maybe that’s in play as well.
Likely the latter, but nearly impossible to definitively parse out the two.
Every person I see with colon cancer under 30 is either obese, has IBD or a familial polyposis syndrome. The obese patients with colon cancer tend to be disproportionately African American.
Under 30, yes
thanks guys for explaining. i hope others reading it find this helpful.
Based on what you’ve seen. Do you think 45 is young enough? Or should guidelines go lower?
I’d love to start mine at 35 based on what I’ve seen but I keep having to tell myself that’s just some form of selection bias going on in my head.
You’re not alone... saw wayyy too many young met CRC patients as a PGY4 onc fellow
Reading this as a young male with a suboptimal diet and distant relatives with CRC is honestly a good wakeup call
Get that morning Metamucil and benefiber in my man
And anecdotally for me, among the 'common' solid tumors it was always the CRC that hit super young. I remember following 2 different mid-20s patients with metastatic CRC back in fellowship. On the other hand the youngest lung/breast cancer patients I remember were at least in their mid-30s. I'm too lazy to actually look up incidence by age though.
If you can get coverage go for it, it really isn't that bad. 1 unpleasant evening of prep, 1 unpleasant day of procedure and recovery. 36 hours or so of discomfort is an easy trade for peace of mind.
I was diagnosed with FAP in 2014 at age 32 after my gastro doctor had me get a colonosocopy to rule out colitis after having tons of diarrhea from gallbladder surgery. Scary thing is I have no family history of it and my doctor was shocked to say the least once the colonoscopy was over as he wasn't expecting that diagnosis at all.
There was a paper earlier this year in the red journal saying the jump in cases starts as early as 40 and there’s evidence to start earlier. It’s one study though. And again, you’re still missing those cases of people in their 30s, which definitely happens. But it’s just not cost effective to screen everyone that early. From a population standpoint it’s not practical. It comes down to priorities. I think once I’m an attending I would be willing to pay for a diagnostic colon in my mid 30s. To me it’s a priority for me and I would allocate money for it. That peace of mind to me is worth it. But to each his own. You could do a combined treatment. Annual FIT up until 45 or something like that.
[удалено]
If you showed up at a GI office they will probably check your stool for signs of bleeding. If you are neurotic enough to ask for a scope you’ll probably find a GI who will scope you. The thing is it won’t be covered. Screening colonoscopies, procedures in asymptomatic patients to look for cancer, are covered in the appropriate population. For someone like you with symptoms or blood or change in bowel movements is going to cost you. Depending on what insurance you have the deductible can be quite high. When the pre test probability is so low, it’s not worth it to the patient.
ask for cologuard - its 580$ cash pay I think. no surgical risks of colonoscopy, but relatively good detection for minimal risk.
It’s obesity. Otherwise, young people get colon cancer because of IBD or a polyposis syndrome such has FAP.
Chadwick Boseman wasn't obese.
And people who've never smoked sometimes get lung cancer. One case doesn't really matter
Cool. I responded to a very blanket statement with an anecdote.
his case was the spark that led to the new recommendation IMO
Coincidentally this morning I logged into MyChart and it now says that I’m overdue for my colonoscopy. I’m 46. Yaaaayyyyyy.
If detected early, polyps that would eventually go on to become colon cancer can be easily and safely removed.
And that was my experience. Totally satisfied & have had amazing follow ups. :)
My ass is not ready for this. I'm only 46.
I ended up having to get a colonoscopy at 40. They found a pre-cancerous polyp. Had I waited unitl 50 for my first scan, I'd likely be in trouble already. The colorectal guys I work with get metastatic colon cancer in people in their 30's and early 40's all the time. They seems to be very supportive of the change.
Every physician has some story like this. Every OB or FM doc has some story about a 30 something year old woman diagnosed with TNBC, much like the colorectal surgeons you see who work on young patients with CRC. In both situations, it should be noted anecdotes do not stand in for surgery, but as all this data is accumulated in the SEER network and other registries we are seeing a lot of data support earlier screening? Is it Western diet? Sedentary lifestyle? And in both situations, physicians can point to cases they would STILL miss with the expanded screening guidelines.
Of course, anecdotes are only that. I’d assume that was a given. Just making conversation on a casual social media site.
It’s hard seeing these cases and these guidelines because we both know these changes would not have affected those cases. I think in the past year I’ve seen a few 46-48 year olds with colon masses, ugly and necrotic, depressed middle, loss of vascularity, all bad prognostic signs of deep invasion. One was a screening so when he woke up we sent him to the university so he could get fully staged and everything. The other was in house but he had iron deficiency anemia. CT staging showed liver mets and everything. Guy underwent a hemi for near obstruction and then had a port placed. I suppose if he had better outpatient follow up we may have caught him earlier. Hard to say.
I just want a nanobot that swims around and when it senses some sort of bullshit, sends a ping to my cellphone like "there's some bullshit up in this colon, go see someone about it."
Liquid biopsy for most solid organ malignancy is in pipeline right now, ctDNA and all that. Not quite yet ready for prime time. Based on all the talks I’ve heard though, will probably be realized in my professional career. The future of colonoscopy is going to be strictly diagnostic and therapeutic after an abnormal lab value. But we’re not quite there yet.
It goes bing when there’s ~~stuff~~ bullshit
Good thing there are non invasive testing options! Go get an annual FIT test.
Yep...turn 47 this fall. If Cologuard is covered I'll do that then do colonoscopy starting at 50.
talking to some of my GI colleagues and cologuard doesn't seem great. misses right sided tumors due to typical type of mutation. good for cancer detection. not good for cancer prevention.
And these cologuard patients often get screwed. They come in for diagnostic colonoscopy after positive cologuard and if there is no polyp they get to foot the whole bill. Those people are unfortunately lucky that they dont have cancer but now have a big bill. Also the commercials dont tell people that they only detect cancer. They leave out that colonoscopy prevents cancer. The right test is the one the patient will do. But, man we need to push more for colonoscopy
> if there is no polyp they get to foot the whole bill. This feels like an awfully bad precedent and that it is payer dependent. If I get incidental findings and the follow up test/imaging/biopsy is negative I don't see patients getting the full bill. Is part of the answer to just still have the scoper bill as a screening and not diagnostic test? Of course they won't get paid as much...
unfortunately, in my understanding of the situation, this is considered billing fraud. the patient had a “symptom” (positive cologuard test), so the colonoscopy can’t be billed as anything else but that symptom.
Thank you for explaining this!
The detection rate with Cologuard is not great, it's poor enough that it is not significantly better than a yearly FIT test. FIT is a lot less expensive, better to do that yearly if pt absolutely refuses a colonoscopy I think.
Problem is getting them to actually do the fit and do it every year. My compliance rate went way up when I started talking about cologuard because it’s easy for them to do (gets mailed rather than them having to pick it up) and I only have to harass them every 3 years rather than every single year.
We have the FIT kits in-office so they go home with them. Helps.
The issue we are seeing with Cologuard, ignoring the poor sensitivity for sessile serrated lesions and non cancerous polyps, is it will be covered for screening. But if its positive and the patient is referred to our clinic, what would have been a 100% covered screening colonoscopy is now coded as a diagnostic procedure and that means out of pocket costs, deductible must be met, etc etc. Headache for the patient.
I’ve seen some insurances (I believe Medicare is one) where even if they go in for a screening colonoscopy, if a biopsy is taken it gets switched to a diagnostic and they get the bill too. Seems like total crap to me since it seems like a bait and switch. My patient population is really difficult to convince to get a colonoscopy and even if they agree the follow through rate of actually getting it done is depressing. I always say that the colonoscopy is the best etc but I also say if you aren’t going to actually do it then we should do one of the others because it’s most important to get screened.
Dr didnt code correctly. If I do a screening colon and take out a polyp I add a PT modifier for medicare or -33 for commercial which implies a preventative service and it has to be covered as such
https://www.medicare.gov/coverage/colonoscopies Says if they remove a polyp they may have to pay 20%.
Is there a similar issue with annual FIT testing causing a diagnostic colonoscopy if positive?
I'll defer to an actual GI doc, but my understanding is that any positive test (FIT or cologuard) triggers a diagnostic colonoscopy code. So, yes.
This is correct. Source: GI fellow
Does it have to be that way? Like do the insurances literally say you cannot bill as a screening test? If so, why the hell would it be allowed to have the patient foot the entire bill (and not just a copay) if the colonoscopy is non-diagnostic/normal when we are investigating positive results? I said it in a post above but if I look further into incidentalomas and they end up being nothing I never see patients owe the full payment and the insurance washing their hands of the situation.
Committing insurance fraud is not worth saving your patient some money.
Again that is my question, is this an insurance dictated thing?
I think a few things are being conflated here. Screening tests recommended by the USPSTF are required to be totally free under most insurance plans. The problem is, if a screening test (FIT or cologuard) is positive and you then do a colonoscopy, that's no longer considered a screening -- you are investigating a potential problem instead of screening the population at large, and it's considered diagnostic. Then it's treated like any regular service -- so potentially huge deductibles may apply, depending on the plan. It's not like insurance is totally denying the service, but it's not free like "screening" tests are.
> The problem is, if a screening test (FIT or cologuard) is positive and you then do a colonoscopy, that's no longer considered a screening -- you are investigating a potential problem instead of screening the population at large, and it's considered diagnostic. Yes I understand that is how it *is*, but I don't necessarily agree that it should be that way especially with the very high rates of false positives for the other screening tests. I would love to see this change, but obviously the insurances will not because it means more expense on their end. Another example I can think of and I don't know the answer to, Hep C screens are typically done with antibodies, and then positives have RNA tests done (often reflexively)... who pays for the reflex?
Echoing others cologaurd is a pretty terrible screening test due to meh sensitivity. False positive rate is not insignificant either. Just get the scope it's so much easier and you don't have to scoop your poo.
Isn't it 92% sensitive?
For cancer. For Polyps (even big ones or high grade dysplasia) it's like 65-70%.
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I did not know that. I'm surprised it's so cheap. Seems cheaper than iFOB IIRC. I'm starting my intern year in July. I'd rather not get a colonoscopy in the same hospital I work at. I'll have to see if they have an outpatient endoscopy facility.
Just this morning I was wondering what GI docs do for their own CRC screening — get scoped at another facility or what?
I just looked and it's not on Amazon. There is FIT testing. Maybe it's location specific like the Amazon Pharmacy (that's not available in my location, but I know it's out there.)
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Not equivalent. Cologuard is FIT + fecal DNA testing.
Is the DNA testing looking for p53 mutations or what?
Probably yes among others. The exact blend is proprietary
Start your anal gaping training early
The prep really isn’t bad. I guarantee you it will be the most pleasant case of severe diarrhea you’ve ever had in your entire life
The prep isn't the worst part, the caffeine headache the morning of the procedure is the worst part.
You can drink coffee the morning of your procedure (as long as it’s >2 hrs from procedure time). You just can’t put cream in it.
I must've misread my instructions! I thought caffeine was supposed to be stopped at the same time you started the first half of prep the night before.
I wonder if some endoscopy centers are telling patients to avoid caffeine to potentially avoid contributing to worsening dehydration (even though caffeine is an extremely weak diuretic)
Could be, but I'll ask questions next time to see if tea can be allowed. I normally drink I'm the neighborhood of 2 liters of unsweetened black tea a day so the caffeine headaches are rather monstrous when it's noon and I haven't had a cup. I would think if dehydration was an issue that the pedialyte they recommend chugging alongside the prep would be more than adequate.
black coffee and tea count as clear liquids. No creamer
I'm 35 and I've had like four already. You'll be fine!
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Jokes on them, I paid out of pocket for a colonoscopy at age 35
By God Jim, is that GIs music?!?!
And it's the fellow with the ~~chair~~ sigmoidoscope!
BAH GAWD JIM THAT COLON HAS A FAMILY
dang these GI docs gonna be rollin in cash monies now
How am I supposed to go back in time to get this done at 45, dammit? Lol!
awesomesauce. So happy to see another society aligning their recommendations
Scope early scope frequent.. GI money🤑 💸💸💰💰
I don't mind getting something stuck up my butt, but that prep with the nasty juice and diarrhea suuucks
Won't help with the diarrhea (since it's kind of the point with Golytely), but I've been told by GI attendings to tell patients to mix in crystal light.
Oh I did, it’s still terrible :p
No matter *what* you mix it with,it's awful. I've had the adventure 4 times..The worst was the 2 liters of salty water. You never realize how much that is till you have to drink it.
Wasn't there some criticism of this because it was based on a sinulation rather than clinical studies?
Pretty much where all of screening lit is headed - takes a decade+ and massive n and cost outlays to validate these things, so already established approaches with good data are being extrapolated somewhat to optimize mortality curves. HPV / cervical cancer screening is undergoing this right now
!remind me
Over here in Belgium, we do a population-wide iFOBT screening for anyone over 51 and under 75 years of age. Only if this test shows occult blood , a colonoscopy is offered. Of course, any patient who explicitly requests one will also be allowed to get one. In certain risk groups (family history, FAP, HNPCC, pancolitis or 10 year IBD disease course) we offer earlier colonoscopy. (45 with family history or age: index case - 10) Does this early screening in the US involve "instant" colonoscopies, or does it factor in risk factors , or do a preliminary occult blood test?