Health Information Management

Q/A: Is patient considered high risk after non-adenomatious polyp removal?

APCs Insider, August 28, 2009

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Q: Is a patient who underwent a colonoscopy and polyp removal three years ago considered high risk if the polyp was not adenomatous per pathology? Does removal of this type of polyp indicate whether the patient is at high risk?   
A: Medicare covers various screening tests to help find colorectal cancer itself or identify and remove precancerous polyps (growths in the colon). Coverage for these tests varies based on a beneficiary's risk for colorectal cancer. The Medicare Colorectal Cancer Web site indicates that a beneficiary is considered to be at high risk if any of these risk factors are present:   
  • A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp (a type of polyp that could become cancerous)
  • A family history of familial adenomatous polyposis (this involves multiple adenomatous polyps, often in the hundreds, and carries a very high risk of colon cancer)
  • A family history of hereditary nonpolyposis colorectal cancer (a type of colorectal cancer that runs in families and tends to cause cancer at a relatively young age—under 45 years)
  • A personal history of adenomatous polyps
  • A personal history of colorectal cancer
  • A personal history of inflammatory bowel disease, including Crohn's Disease and ulcerative colitis
Hospitals should review their most current Local Coverage Determinations for both screening and diagnostic lower endoscopy exams. Hospitals also should engage in further discussion regarding specific fiscal intermediary (FI) or Medicare administrative contractor (MAC) instructions with the FI or MAC.

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