Medicare proposes paying for CT colonography under hospital outpatient rule, drawing praise from radiology community

The Centers for Medicare & Medicaid Services on Wednesday proposed paying for CT-based colon cancer screening, drawing praise from the radiology community.

CMS issued its decision as part of the 2025 Hospital Outpatient Prospective Payment System proposed rule. The American College of Radiology has lobbied for this policy change since at least 2008, labeling CTC as a solid alternative to a colonoscopy.

“ACR applauds this proposal as a big step forward toward providing Medicare patients access to a minimally invasive CRC screening tool that can detect precancerous polyps and does not require anesthesia,” the college said in a statement issued Wednesday morning.

Medicare reimbursement for a “virtual colonoscopy” would total about $106.30. However, this would only be for the hospital’s technical component of the service. CMS had only released the OPPS rule as of late Wednesday morning. The professional component and freestanding center technical component will be detailed in the 2025 Medicare Physician Fee Schedule, which the federal agency is expected to issue soon.

Members of ACR’s Colon Cancer Committee recently met with the acting director of the Center for Clinical Standards and Quality, along with other CMS staff, to discuss the benefits of CTC. Radiologists presented information about the screening option, noting its lack of anesthesia makes it “a great option for beneficiaries who have little to no paid time off work, a fear of sedation or logistical challenges such as transportation.” Billionaire “Shark Tank” investor Mark Cuban highlighted his positive experience with the service on social media in 2021, calling it “fast and easy” with the option to drive oneself home afterward.

ACR first began its push for CTC payment after publishing the results of its Imaging Network National CT Colonography Trial in 2008. The large, multicenter study showed that computed tomography is highly accurate for the detection of large and intermediate polyps. The college formally asked for Medicare coverage after the trial, but CMS rejected the request in 2009 “and continued to deny several reconsideration requests until now,” ACR noted.

"The ACR has been working tirelessly for over a decade to obtain CMS coverage for screening CTC to help get more patients screened for colon cancer," Judy Yee, MD, chair of the ACR Colon Cancer Committee and a long-time advocate on this issue, told Radiology Business. "CMS coverage for this less invasive colon cancer screening test will help with improved access of this potentially life-saving test for underserved communities where screening rates are lower and colon cancer death rates are much higher. CTC has been an untapped resource that will be beneficial to broadening screening options and will also help to mitigate increasing screening demands secondary to the continued significant increase in the size of the Medicare population." 

Colorectal cancer is the leading cancer killer among men under 50 and No. 2 on the list for women of the same age. Black Americans are 20% more prone to developing the disease and 40% more likely to die from it, American Cancer Society data show. “Even more alarming,” ACR reported Wednesday, physicians will diagnose about 106,590 new cases of colon cancer this year alone.

Current Procedural Terminology codes for the service are 74261 for a CT colonography without dye and 74262 for the same service with dye, according to the 984-page proposed rule.

“In recent years we have received recommendations from the public to remove Medicare coverage for the barium enema test since the test no longer meets modern clinical standards and is no longer recommended in clinical guidelines,” CMS noted in the document. “As a replacement to the barium enema test, organizations have suggested the use of CT colonography, which is a more effective test for colorectal cancer screening. For a more extensive discussion on the background and proposal to revise the Medicare coverage for colorectal cancer screening services, we refer readers to the CY 2025 Physician Fee Schedule proposed rule. For CY 2025, based on public input and consultation with specialty societies, and as discussed in the CY 2025 PFS proposed rule, we propose to exercise our authority under section 1861(pp)(1)(D) of the Act to update and expand coverage for CRC screening.”

For more on the OPPS proposed rule, you can read this CMS fact sheet and separate news release. ACR also released a preliminary summary of the hospital outpatient rule and an additional update noting the inclusion of CTC in the 2025 Medicare Physician Fee Schedule. 

Editor's Note: This article has been updated to include additional links from ACR and a quote from Judy Yee.