March is National Colorectal Cancer Awareness Month. Most everyone is familiar with these three points:
The risk of getting colorectal cancer increases with age
More than 90% of cases occur in people who are 50 years old or older
Colorectal cancer can often be prevented
To better serve your patients and help save lives, now is the time to review current information available on statistics, causes and prevention.
American Cancer Society Statistics:
Excluding skin cancers, colorectal cancer is the third most common cancer diagnosed in both men and women in the United States, with the lifetime risk of developing it about 1 in 20.
Estimates for the number of colorectal cancer cases in the United States for 2013 are:
•102,480 new cases of colon cancer
•40,340 new cases of rectal cancer
Colorectal cancer is expected to cause about 50,830 deaths during 2013.
Good News: The death rate (the number of deaths per 100,000 people per year) from colorectal cancer has been dropping in both men and women for more than 20 years. There are now more than 1 million survivors of colorectal cancer in the United States.
Causes of Colorectal Cancer:
Being overweight or obese raises the risk both of being diagnosed and dying from this disease. Most cases of colorectal cancer start as a non-cancerous growth called a polyp.
Studies have found that people who are overweight or obese are more likely to develop these polyps, and higher weights are associated with higher polyp risk.
A diet that is high in red meat and processed meat (like luncheon meats and hot dogs) increases the risk of developing the disease.
Hereditary factors play a significant role in colorectal cancer risk.
Note: Medicare defines high risk of developing colorectal cancer as someone who has one or more of the following risk factors:
• Close relative(sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp,
• Family history of adenomatous polyposis,
• Family history of hereditary nonpolyposis colorectal cancer,
• Personal history of adenomatous polyposis,
• Personal history of colorectal cancer, or
• Personal history of inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis.
Colorectal Cancer Prevention: Education, screening and early detection saves lives.
Education: Encourage patients to lower their risk for colorectal cancer by not smoking, maintaining a healthy weight and exercising. Recommend that your patients eat more vegetables, fruits, and whole grains, and less red meat (beef, lamb, or pork) and less processed meat (hot dogs and some luncheon meat). Men should limit alcohol to no more than 2 drinks a day, and women to no more than 1 drink a day.
Screening: Talk with your patients about the importance of getting screened for the disease. Regular screening can find precancerous polyps so they can be removed before they turn into cancer. The American Cancer Society recommends regular colon cancer screening for most people starting at age 50. People with a family history of the disease or other risk factors should talk with their doctor about beginning screening at a younger age.
Medicare beneficiaries age 50 and over are covered for colorectal cancer screenings services and should be encouraged to take full advantage. Covered services vary based upon the patient’s individual risk category. (See chart below)
Early detection:
The earlier colorectal cancer is diagnosed, the greater the chance the treatment will be the most effective. Early detection typically means the cancer is discovered at its earliest pathological stage, Stage I or IIA. Five-year survival Statistics from National Cancer Institute's SEER database for cases diagnoses from 1998-2000 are:
Rectal Cancer: Stage I 74% and Stage IIA 65%
Colon Cancer: Stage I 74% and Stage IIA 67%
The most advanced stage, Stage IV only sees about a 6% five-year survival rate for both.
Advances in current treatment methods have had significant effects on survival rates. If diagnoses at the localized stage level, the five-year survival rate for people with colorectal cancer is 90%. If the cancer has spread to nearby lymph nodes or organs, the five-year survival rate is 70%. If the cancer has spread to distant parts of the body, the five-year survival rate is 12%.
Coverage Information for Medicare beneficiaries
G0328-immunoassay 1-2 simultaneous OR
82270 by peroxidase activity, qualitative
Contact your local Medicare Contractor for Guidance.
Flexible Sigmoidoscopy
Every 4 years (if following a screening colonoscopy, then after at least 119 months)
G0104 : Contact your local Medicare Contractor for Guidance.
Colonoscopy
Every 10 years (if following sigmoidoscopy, then after at least 47 months)
G0121 : Contact your local Medicare Contractor for Guidance.
As an alternative to flexible sigmoidoscopy
G0106 : Contact your local Medicare Contractor for Guidance.
Fecal Occult Blood Test (FOBT)
Every year
G0328-immunoassay 1-2 simultaneous OR
82270 by peroxidase activity, qualitative
Contact your local Medicare Contractor for Guidance.
Flexible Sigmoidoscopy
Every 4 years
G0104
Contact your local Medicare Contractor for Guidance.
Colonoscopy
Every 2 years (if following a sigmoidoscopy, then after at least 47 months) : G0105
Contact your local Medicare Contractor for Guidance.
As an alternative to colonoscopy : G0120
Contact your local Medicare Contractor for Guidance.
Medicare beneficiary financial responsibility will be:
Codes G0104, G0105, G0121, G0328 and 82270: $0 out of pocket (deductible and coinsurance waived)
Codes G0106 and G0120: 20% co-insurance based on Medicare allowed amount (deductible waived)
Codes 10000-69999 furnished for same date/encounter as colorectal cancer screening services will also not be subject to deductible.
Billing Note: Apply modifier –PT to at least one code in this range to indicate this scenario.
Community-Based Care Transition Program (CCTP)-Working to Prevent Hospital Readmissions
CMS data suggests almost 20% of hospitalized Medicare patients are readmitted within 30 days of their discharge.
This amounts to approximately 2.6 million beneficiaries being affected and costs the Medicare program an estimated $26 billion every year.
In an attempt to curb this expense, the CMS Innovation Center established by the Affordable Care Act has created the Community-Based Care Transition Program (CCTP). The ACA has earmarked up to $500 million for the CCTP that was launched in 2011 and will run for 5 years.
The program starts with the basic principle that the healthcare community should work together to improve quality of patient care.
The goal is to ultimately reduce hospital readmissions by a minimum of 20 % which would translate to a savings of $5.2 billion a year. This represents a significantly larger amount than the initial cost to CMS for the program.
Data for 2012 suggests the program is already working by preventing an estimated 70,000 readmissions.
Enrolled participants, referred to as Community-based organizations (CBOs) now numbering over 100, will work with hospitals to coordinate patient care transitions. If you would like to see who is participating in your area, you can select this link to access the CMS interactive map: http://innovation.cms.gov/initiatives/map/index.html?modelPass=CCTP
Care transitions as referred to in this program, relate to hospital inpatients that are being discharged to their home, a nursing home, or other care facility. CBOs will use care transition services to identify risk factors that produce readmissions and coordinate the necessary actions to lessen the effect of those factors.
CBOs will be required to provide:
Care transition services that begin no later than 24 hours prior to discharge
Timely, culturally and linguistically competent post-discharge education to patients
NOTE:This education is crucial so that patients understand potential additional health problems that may develop or a deteriorating condition.
Timely interactions between patients and post-acute and/or outpatient providers.
Patient centered self-management support and information specific to the beneficiary’s condition
A comprehensive medication review and management
NOTE: This includes any appropriate counseling and self-management support.
The CBOs will be paid an all-inclusive rate per eligible discharge based on the cost of care transition services provided at the patient level and of implementing systemic changes at the hospital level. CBOs will only be paid once per eligible discharge in a 180-day period of time for any given beneficiary.
Performance and effectiveness of the CBOs will be gauged by the evaluation contractor and the implementation and monitoring contractor. Quality and utilization measures will consist of 30-day all cause readmission rates, and will also monitor 90-and 180-day readmission rates, mortality rates, observation services, and emergency department visits.
One major goal of the CCTP is to develop effective approaches to care interventions that will improve the quality of care while decreasing readmissions. This transparency of the COB’s should ensure accurate evaluations of both successes and shortcomings of this program.
Are Accountable Care Organizations (ACOs) only for Medicare beneficiaries?
At the present time, Medicare funds are supporting ACO formation around the country to serve Medicare beneficiaries. In January 2013, CMS announced 106 new organizations will be participating in the Medicare-sponsored ACO programs, taking the participation numbers to over 250 nationwide.
Additionally, some states are looking at the ACO to service Medicaid patients in their attempt to improve quality and reduce costs.
Some commercial insurers are supporting ACO development for their own members as well.
Innovative physician-led organized groups have been following the ACO care model with all of their patients for decades and are participating in both Medicare and commercial ACO pilot programs.
The intention of the Affordable Care Act is that ACOs will eventually be available to everyone. Multispecialty medical groups, physician-hospital organizations (PHOs), integrated delivery systems (IDSs), and independent practice associations (IPAs) are likely candidates to become the ACOs of the future.
ACO Programs at CMS
Medicare offers several ACO programs, including:
Medicare Shared Savings Program (cms.gov) - For fee-for-service beneficiaries
Advance Payment ACO Model - For certain eligible providers already in or interested in the
Medicare Shared Savings Program
Pioneer ACO Model - Health care organizations and providers already experienced in coordinating care for patients across care settings
ACO: Accelerated Development Learning Sessions - For existing or emerging Accountable Care Organizations (ACOs) to develop a broad and deep understanding of how to establish and implement core functions to improve care delivery and population health while reducing growth in costs.
General information on ACOs can also be found at cms.gov/aco and this HealthCare.gov ACO Fact Sheet.
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