COVERAGE OF COLORECTAL SCREENING.

SEC. 4104. COVERAGE OF COLORECTAL SCREENING. (a) Coverage.— (1) In general.—Section 1861 (42 U.S.C. 1395x), as amended by section 4103(a), is amended— (A) in subsection (s)(2)— (i) by striking “and” at the end of subparagraph (P); (ii) by adding “and” at the end of subparagraph (Q); and (iii) by adding at the end the following new subparagraph: “(R) colorectal cancer screening tests (as defined in subsection (pp)); and”; and (B) by adding at the end the following new subsection: “Colorectal Cancer Screening Tests “(pp)(1) The term ‘colorectal cancer screening test’ means any of the following procedures furnished to an individual for the purpose of early detection of colorectal cancer: “(A) Screening fecal-occult blood test.111 STAT. 363 “(B) Screening flexible sigmoidoscopy. “(C) In the case of an individual at high risk for colorectal cancer, screening colonoscopy. “(D) Such other tests or procedures, and modifications to tests and procedures under this subsection, with such frequency and payment limits, as the Secretary determines appropriate, in consultation with appropriate organizations. “(2) In paragraph (1)(C), an ‘individual at high risk for colorectal cancer’ is an individual who, because of family history, prior experience of cancer or precursor neoplastic polyps, a history of chronic digestive disease condition (including inflammatory bowel disease, Crohn’s Disease, or ulcerative colitis), the presence of any appropriate recognized gene markers for colorectal cancer, or other predisposing factors, faces a high risk for colorectal cancer.”. (2) Deadline for publication of determination on coverage of screening barium enema.—Not later than the earlier of the date that is January 1, 1998, or 90 days after the date of the enactment of this Act, the Secretary of Health and Human Services shall publish notice in the Federal Register with respect to the determination under paragraph (1)(D) of section 1861(pp) of the Social Security Act (42 U.S.C. 1395x(pp)), as added by paragraph (1), on the coverage of a screening barium enema as a colorectal cancer screening test under such section. (b) Frequency Limits and Payment.— (1) In general.—Section 1834 (42 U.S.C. 1395m) is amended by inserting after subsection (c) the following new subsection: “(d) Frequency Limits And Payment for Colorectal Cancer Screening Tests.— “(1) Screening fecal-occult blood tests.— “(A) Payment amount.—The payment amount for colorectal cancer screening tests consisting of screening fecal-occult blood tests is equal to the payment amount established for diagnostic fecal-occult blood tests under section 1833(h). “(B) Frequency limit.—No payment may be made under this part for a colorectal cancer screening test consisting of a screening fecal-occult blood test— “(i) if the individual is under 50 years of age; or “(ii) if the test is performed within the 11 months after a previous screening fecal-occult blood test. “(2) Screening flexible sigmoidoscopies.— “(A) Fee schedule.—With respect to colorectal cancer screening tests consisting of screening flexible sigmoidoscopies, payment under section 1848 shall be consistent with payment under such section for similar or related services. “(B) Payment limit.—In the case of screening flexible sigmoidoscopy services, payment under this part shall not exceed such amount as the Secretary specifies, based upon the rates recognized for diagnostic flexible sigmoidoscopy services. “(C) Facility payment limit.— “(i) In general.—Notwithstanding subsections (i)(2)(A) and (t) of section 1833, in the case of screening 111 STAT. 364flexible sigmoidoscopy services furnished on or after January 1, 1999, that— “(I) in accordance with regulations, may be performed in an ambulatory surgical center and for which the Secretary permits ambulatory surgical center payments under this part, and “(II) are performed in an ambulatory surgical center or hospital outpatient department, payment under this part shall be based on the lesser of the amount under the fee schedule that would apply to such services if they were performed in a hospital outpatient department in an area or the amount under the fee schedule that would apply to such services if they were performed in an ambulatory surgical center in the same area. “(ii) Limitation on deductible and coinsurance.—Notwithstanding any other provision of this title, in the case of a beneficiary who receives the services described in clause (i)— “(I) in computing the amount of any applicable deductible or copayment, the computation of such deductible or coinsurance shall be based upon the fee schedule under which payment is made for the services, and “(II) the amount of such coinsurance is equal to 25 percent of the payment amount under the fee schedule described in subclause (I). “(D) Special rule for detected lesions.—If during the course of such screening flexible sigmoidoscopy, a lesion or growth is detected which results in a biopsy or removal of the lesion or growth, payment under this part shall not be made for the screening flexible sigmoidoscopy but shall be made for the procedure classified as a flexible sigmoidoscopy with such biopsy or removal. “(E) Frequency limit.—No payment may be made under this part for a colorectal cancer screening test consisting of a screening flexible sigmoidoscopy— “(i) if the individual is under 50 years of age; or “(ii) if the procedure is performed within the 47 months after a previous screening flexible sigmoidoscopy. “(3) Screening Colonoscopy for Individuals at High Risk for Colorectal Cancer.— “(A) Fee schedule.—With respect to colorectal cancer screening test consisting of a screening colonoscopy for individuals at high risk for colorectal cancer (as defined in section 1861(pp)(2)), payment under section 1848 shall be consistent with payment amounts under such section for similar or related services. “(B) Payment limit.—In the case of screening colonoscopy services, payment under this part shall not exceed such amount as the Secretary specifies, based upon the rates recognized for diagnostic colonoscopy services. “(C) Facility payment limit.— “(i) In general.—Notwithstanding subsections (i)(2)(A) and (t) of section 1833, in the case of screening 111 STAT. 365colonoscopy services furnished on or after January 1, 1999, that are performed in an ambulatory surgical center or a hospital outpatient department, payment under this part shall be based on the lesser of the amount under the fee schedule that would apply to such services if they were performed in a hospital outpatient department in an area or the amount under the fee schedule that would apply to such services if they were performed in an ambulatory surgical center in the same area. “(ii) Limitation on deductible and coinsurance.—Notwithstanding any other provision of this title, in the case of a beneficiary who receives the services described in clause (i)— “(I) in computing the amount of any applicable deductible or coinsurance, the computation of such deductible or coinsurance shall be based upon the fee schedule under which payment is made for the services, and “(II) the amount of such coinsurance is equal to 25 percent of the payment amount under the fee schedule described in subclause (I). “(D) Special rule for detected lesions.—If during the course of such screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the lesion or growth, payment under this part shall not be made for the screening colonoscopy but shall be made for the procedure classified as a colonoscopy with such biopsy or removal. “(E) Frequency limit.—No payment may be made under this part for a colorectal cancer screening test consisting of a screening colonoscopy for individuals at high risk for colorectal cancer if the procedure is performed within the 23 months after a previous screening colonoscopy.”. (c) Conforming Amendments.—(1) Paragraphs (1)(D) and (2)(D) of section 1833(a) (42 U.S.C. 13951(a)) are each amended by inserting “or section 1834(d)(1)” after “subsection (h)(1)”. (2) Section 1833(h)(1)(A) (42 U.S.C. 13951(h)(1)(A)) is amended by striking “The Secretary” and inserting “Subject to section 1834(d)(1), the Secretary”. (3) Section 1862(a) (42 U.S.C. 1395y(a)), as amended by section 4103(c), is amended— (A) in paragraph (1)— (i) in subparagraph (F), by striking “and” at the end, (ii) in subparagraph (G), by striking the semicolon at the end and inserting “, and”, and (iii) by adding at the end the following new subparagraph: “(H) in the case of colorectal cancer screening tests, which are performed more frequently than is covered under section 1834(d);”; and (B) in paragraph (7), by striking “or (G)” and inserting “(G), or (H)”. (d) Payment Under Physician Fee Schedule.—Section 1848(j)(3) (42 U.S.C. 1395w–4(j)(3)), as amended by sections 4102 and 4103, is amended by inserting “(2)(R) (with respect to services 111 STAT. 366described in subparagraphs (B) , (C), and (D) of section 1861(pp)(1)),” before “(3)”. (e) Effective Date.—The amendments made by this section shall apply to items and services furnished on or after January 1, 1998.