Understanding the history of computed tomography colonography (CTC) coding is important to helping us learn how it will impact the future.
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By Liz Zhe Lin, MD, ACR Moorefield Fellow, Massachusetts General Hospital
Undeniably, the story of CTC insurance coverage is one of hard-fought triumph, brought about by countless champions over a multi-decade process. In honor of Colorectal Cancer Awareness Month, let us reflect on the history of CTC coding and better understand it as we move into the future.
CTC was developed in the mid-1990s through the work of pioneers such as Judy Yee, MD, and Perry J. Pickhardt, MD, which led to its approval by the U.S. Food and Drug Administration for colorectal cancer screening in 2006. Advances in multidetector CT and 3D reconstruction enabled “fly-through” endoluminal visualization of the colon. This was validated in larger trials which demonstrated high sensitivity for advanced adenomas.
In 2008, the American Cancer Society (ACS) included CTC as an accepted colorectal cancer (CRC) screening option. Still, the Centers for Medicare & Medicaid Services (CMS) issued a non-coverage decision for screening CTC in 2009. CMS cited concerns about limited outcomes data, radiation exposure and the potential need for follow-up colonoscopy. This CMS coverage decision prompted ACR to undertake a long-term advocacy effort for CTC reimbursement. In 2016 and 2021, the United States Preventative Services Task Force (USPSTF) added CTC as an effective screening option, with Grade A (ages 50-75)/Grade B (ages 45-49) recommendations defined as high (Grade A) or moderate (Grade B) certainty the net benefit is substantial. In accordance with the Affordable Care Act, USPSTF endorsement with a Grade A or B obligates coverage of screening tests by many payers, including traditional commercial insurers. Nonetheless, a National Coverage Determination (NCD) is required for screening studies to be reimbursed by Medicare. It was not until 2023 that CMS reversed course and approved CTC coverage for Medicare patients.
CMS separates rulemaking approval and claims processing system updates and implementation. As a result, coverage for screening CTC was finalized in the Medicare Physician Fee Schedule (MPFS) Final Rule in Nov. 2023, and operational claims coverage became effective Jan. 1, 2025. This update finally removed a financial barrier to CRC screening care by waiving deductibles and coinsurance for eligible patients to marking the end of a multi-decade advocacy battle fought by multi-society CRC screening coalitions led by the ACR.
Colorectal Cancer Awareness Month is a good opportunity to reflect on the importance of early detection and continued innovation in cancer prevention for both radiologists and their patients.
The Healthcare Common Procedure Coding System (HCPCS) is a standardized coding system used in the U.S. to bill Medicare, Medicaid and most insurers for medical services, procedures, equipment and supplies. Level 1 codes are Current Procedural Terminology (CPT) codes maintained by the American Medical Association (AMA). The main relevant CPT codes for discussing CTC are 74261 (diagnostic, without contrast), 74262 (diagnostic, with contrast and without contrast) and 74263 (screening). This code family was introduced in 2009 (CPT/RUC cycle FEB09/APR09) and became effective on Jan. 1, 2010. 74263, “Computed tomographic (CT) colonography, screening, including image postprocessing”, is specifically for screening and is now only in its second year of Medicare coverage. Previously, Medicare only covered CTC for diagnostic indications, such as incomplete colonoscopy, not for routine screening.
Review of the available Medicare claims data compiled by the AMA (RBRVS DataManager Online) and past work Relative Value Units (wRVUs) gives insight into volumes and values assigned to this code family:
Compared to:
During prior years when screening CTC was not covered by Medicare, researchers determined from a subset of CMS claims data (2011–2020), that for 785,103 colorectal screening events, 645 were screening CTCs, at a rate of 0.08% utilization of CTC for colorectal screening compared to other methods for screening like optical colonoscopy or stool tests. Other datasets demonstrated increased CTC utilization from the Centers for Disease Control and Prevention National Health Interview Survey (n=58,058, 2010-2019), CTC accounted for 0.8% to 1.4% of all CRC screening and doubled in 2021 to 3.5%. Alternatively, some centers report trends of decreased utilization. Screening CTC is a very small fraction of exams compared to other methods for colorectal cancer screening overall, in the number of thousands compared to millions of optical screening colonoscopies conducted in the U.S. per year.
Colorectal Cancer Awareness Month is a good opportunity to reflect on the importance of early detection and continued innovation in cancer prevention for both radiologists and their patients. CTC remains a high-quality option for cancer screening that has the potential to expand access in an era of rising incidence of colorectal cancer in younger adults and longer wait times for medical care. CTC benefits including comparable sensitivities with reduced recovery time compared to gold-standard optical colonoscopy.
Progress in cancer screening depends not only on the development of effective technologies, but also on equitable implementation, with one barrier being insurance coverage. Researchers demonstrated a stronger association between income and screening CTC utilization than with other CRC screening tests, at least prior to Medicare coverage. Traditional Medicaid coverage of CTC and other screening exams is state-dependent. Thus, patients with Medicaid may be a population that underutilizes this screening modality.
Additional challenges remain, such as specialized patient and clinician education, workflow integration, and interdisciplinary collaboration. Starting or maintaining time-intensive CTC service lines with a new generation of radiologists may seem a lower priority than keeping up with ever-increasing clinical volume but is ultimately an essential service to benefit patients. Radiologists will continue to play a critical role not only through technical expertise and accurate interpretation, but also through advocacy work to reduce barriers to effective and less invasive care.
For more information, visit the ACR’s Colon Cancer Screening Resources, RadiologyInfo.org and the ACR’s My CT Colonography Locator Tool to find or add a location near you.
CPT is a registered trademark of the American Medical Association.
