II 109th CONGRESS 1st Session S. 1010 IN THE SENATE OF THE UNITED STATES May 12, 2005 Mr. Santorum (for himself, Mr. Lieberman, Ms. Collins, Mr. Bingaman, Mr. Nelson of Nebraska, Ms. Snowe, Mr. Graham, Mr. Jeffords, Ms. Landrieu, and Mr. Dorgan) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend title XVIII of the Social Security Act to improve patient access to, and utilization of, the colorectal cancer screening benefit under the Medicare Program.

1.

Short title

This Act may be cited as the Colon Cancer Screen for Life Act of 2005.

2.

Sense of Congress

It is the sense of Congress that— (1)colorectal cancer screening tests (as defined in section 1861(pp)(1) of the Social Security Act (42 U.S.C. 1395x(pp)(1)) covered under the medicare program have been severely underutilized, with the Comptroller General of the United States reporting in 2000 that since coverage of such tests was implemented, the percentage of beneficiaries under the medicare program receiving either a screening or a diagnostic colonoscopy has increased by only 1 percent; (2)in recognition of the need to improve rates of colorectal cancer screening in the medicare program, Congress enacted provisions in the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 to require physicians to provide a referral for colorectal cancer screening as part of the new initial preventive physical examination, beginning January 1, 2005; (3)the Centers for Medicare & Medicaid Services should encourage health care providers to use more effective screening and diagnostic health care technologies in the area of colorectal cancer screening; (4)in recent years, the Centers for Medicare & Medicaid Services has subjected colorectal cancer screening tests to some of the largest reimbursement reductions under the medicare program; (5)unlike other preventive screening tests covered under the medicare program, health care providers must consult with beneficiaries prior to furnishing a screening colonoscopy in order to— (A)ascertain the medical and family history of the beneficiary; and (B)inform the beneficiary of preparatory steps that must be taken prior to the procedure; and (6)reimbursement under the medicare program is not currently available for the consultations described in paragraph (5) despite the fact that reimbursement is provided under such program for similar consultations prior to a diagnostic colonoscopy.

3.

Increase in part B reimbursement for colorectal cancer screening and diagnostic tests

(a)

In general

Section 1834(d) of the Social Security Act (42 U.S.C. 1395m(d)) is amended by adding at the end the following new paragraph: (4)

Enhanced part B payment for colorectal cancer screening and diagnostic tests

(A)

Nonfacility rates

Notwithstanding paragraphs (2)(A) and (3)(A), the Secretary shall establish national minimum payment amounts for CPT codes 45378, 45380, and 45385, and HCPCS codes G0105 and GO121 for items and services furnished on or after January 1, 2006, which reflect a 10-percent increase above the relative value units in effect as the nonfacility rates for such codes on December 31, 2005, with such revised payment level to apply to items and services performed in a nonfacility setting. (B)

Facility rates

Notwithstanding paragraphs (2)(A) and (3)(A), the Secretary shall establish national minimum payment amounts for CPT codes 45378, 45380, and 45385, and HCPCS codes G0105 and GO121 for items and services furnished on or after January 1, 2006, which reflect a 30-percent increase above the relative value units in effect as the facility rates for such codes on December 31, 2005, with such revised payment level to apply to items and services performed in a facility setting. (C)

Annual adjustments

In the case of items and services furnished on or after January 1, 2006, the payment rates described in subparagraphs (A) and (B) shall, subject to the minimum payment amounts established in such subparagraphs, be adjusted annually as provided in section 1848. . (b)

No effect on HOPD payments

The Secretary of Health and Human Services shall not take into account the provisions of section 1834(d)(4) of the Social Security Act, as added by subsection (a), in determining the amount of payment for any covered OPD service under the prospective payment system for hospitals outpatient department services under section 1833(t) of such Act (42 U.S.C. 1395l(t)).

4.

Medicare coverage of office visit or consultation prior to a screening colonoscopy or in conjunction with a beneficiary’s decision to obtain such a screening

(a)

Coverage

Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended— (1)in subparagraph (Y), by striking and at the end; (2)in subparagraph (Z), by inserting and at the end; and (3)by adding at the end the following new subparagraph: (AA)an outpatient office visit or consultation for the purpose of beneficiary education, assuring selection of the proper screening test, and securing information relating to the procedure and sedation of the beneficiary, prior to a colorectal cancer screening test consisting of a screening colonoscopy or in conjunction with the beneficiary’s decision to obtain such a screening, regardless of whether such screening is medically indicated with respect to the beneficiary; . (b)

Payment

(1)

In general

Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended— (A)by striking and before (V); and (B)by inserting before the semicolon at the end the following: , and (W) with respect to an outpatient office visit or consultation under section 1861(s)(2)(AA), the amounts paid shall be 80 percent of the lesser of the actual charge or the amount established under section 1848. (2)

Payment under physician fee schedule

Section 1848(j)(3) of the Social Security Act (42 U.S.C. 1395w–4(j)(3)) is amended by inserting (2)(AA), after (2)(W),. (3)

Requirement for establishment of payment amount under physician fee schedule

Section 1834(d) of the Social Security Act (42 U.S.C. 1395m(d)), as amended by section 3, is amended by adding at the end the following new paragraph: (5)

Payment for outpatient office visit or consultation prior to screening colonoscopy

With respect to an outpatient office visit or consultation under section 1861(s)(2)(AA), payment under section 1848 shall be consistent with the payment amounts for CPT codes 99203 and 99243. . (c)

Effective date

The amendments made by this section shall apply to items and services provided on or after January 1, 2006.

5.

Waiver of deductible for colorectal cancer screening tests

(a)

In general

The first sentence of section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)) is amended— (1)by striking and before (6); and (2)by inserting before the period at the end the following: , and (7) such deductible shall not apply with respect to colorectal cancer screening tests (as described in section 1861(pp)(1)). (b)

Conforming amendments

Paragraphs (2)(C)(ii) and (3)(C)(ii) of section 1834(d) of the Social Security Act (42 U.S.C. 1395m(d)) are each amended— (1)by striking deductible and in the heading; and (2)in subclause (I), by striking deductible or each place it appears. (c)

Effective date

The amendments made by this section shall apply to items and services furnished on or after January 1, 2006.