Current through Register Vol. 46, No. 19, March 20, 2024
(1) Program and fiscal management shall be
conducted by ensuring strategic planning, implementation, coordination,
integration and evaluation of all programmatic activities and administrative
systems, as well as the development of key communication channels and oversight
mechanisms to aid in these processes. Program management shall ensure that
infrastructure adequately supports service delivery.
(2) Service delivery to screen for colorectal
cancer for participants enrolled in the IGS program shall be provided by local
program coordinators and enrolled heath care providers through contractual
arrangements.
a. The IGS program provides
reimbursement for the following screening tests, procedures, preparations and
tissue analyses when those services are provided by a participating health care
provider who has a provider agreement with the IGS program. Payment is based on
Medicare Part B participating provider rates (Title XIX).
(1) Fecal immunochemical tests
annually;
(2) Colonoscopy every ten
years from initial screen or as prescribed by a physician in accordance with
USPSTF recommendations;
(3)
Biopsy/polypectomy during a colonoscopy;
(4) Bowel preparation;
(5) Moderate sedation for
colonoscopy;
(6) One office visit
related to IGS program-covered colorectal cancer tests;
(7) One office visit related to colorectal
cancer follow-up diagnostic test results;
(8) Total colon examination with either
colonoscopy (preferred) or double contrast barium enema if medically prescribed
by doctor;
(9) Pathology
services;
(10) CT colonography (or
virtual colonoscopy) as recommended by provider;
(11) Stool DNA (sDNA) test every three
years;
(12) Care or services for
complications that result from screening or diagnostic tests provided by the
IGS program at the discretion of the department and based on the availability
of funds.
b. The IGS
program does not provide reimbursement for the following:
(1) Screening tests requested at intervals
sooner than recommended by the USPSTF;
(2) Computed tomography scans (CT or CAT
scans) requested for staging or other purposes;
(3) Surgery or surgical staging;
(4) Any treatment related to the diagnosis of
colorectal cancer;
(5) Medical
evaluation of symptoms that make individuals at high risk for CRC;
(6) Management and testing (e.g.,
surveillance colonoscopies and medical therapy) for medical conditions,
including inflammatory bowel disease, ulcerative colitis or Crohn's
disease;
(7) Genetic testing for
participants who present with a history suggestive of a hereditary nonpolyposis
colorectal cancer (HNPCC) or familial adenomatous polyposis (FAP);
and
(8) Treatment for colorectal
cancer.
c. A local
program that has a signed contract with the IGS program shall be responsible
for the following:
(1) Recruitment of
participants;
(2) Eligibility
determination;
(3)
Enrollment;
(4) Patient support
services;
(5) Tracking of follow-up
care;
(6) Documentation and data
reporting; and
(7) Recall of
participants who remain eligible for continued services.
d. Local program coordinators must use a case
management services approach throughout the screening process to ensure that
all participants:
(1) Receive program
information and colorectal cancer educational materials;
(2) Are assisted, according to each
participant's need, to reduce barriers to screening including, for example,
fears, cultural beliefs, language, transportation, understanding of
information, and insurance enrollment;
(3) Receive guidance throughout the
screening, diagnostic and treatment processes;
(4) Understand colorectal cancer screening
procedures and health care provider recommendations;
(5) Receive appropriate services according to
diagnosis including follow-up; and
(6) Have the opportunity to get questions
answered throughout the process.
e. A health care provider that has a provider
agreement with the department shall be subject to the following provisions:
(1) The health care provider agrees that
reimbursement of procedures and services provided shall not exceed the amount
that would be paid under Medicare Part B participating provider rates of Title
XVIII of the Social Security Act.
(2) The health care provider shall provide
the participant and local program coordinator timely colorectal cancer
screening results and follow-up recommendations.
(3) The gastrointestinal health care provider
shall submit pathology specimens to a Clinical Laboratory Improvement
Amendments (CLIA)-certified laboratory for processing.
(4) The health care provider shall practice
according to the current standards of medical care for colorectal cancer early
detection, diagnosis and treatment.
(5) The health care provider or entity shall
submit universal claim forms, originals of the HCFA 1500 or the UB 92, for
reimbursement of IGS program-covered services in accordance with the provider
agreement.
(6) The health care
provider may deliver services in a variety of settings. Service delivery shall
include:
1. Working with local coordinators as
they refer IGS program participants to provide follow-up or initial colorectal
cancer screening services;
2.
Providing a point of contact for program communication with the department to
relay information that may include updating data, follow-up information and
final diagnosis;
3. Providing
screening services for a specific geographic area; and
4. Providing referral and follow-up for
participants with abnormal screening results.
(7) The health care provider shall ensure
compliance with this chapter and other terms and conditions included in the
provider agreement or contract.
(3) IGS program and contracted local program
staff shall conduct referral, tracking and follow-up utilizing a Web-based data
system to monitor each enrolled participant's receipt of screening, rescreening
and diagnostic procedures.
a. The enrolled
participant shall be notified within 30 days of the screening service by
contracted local program staff or the enrolled health care provider of the
results of the service, whether the results are normal, benign or
abnormal.
b. The contracted local
program shall use the IGS program data system to enter appropriate and timely
clinical services, including screening and diagnostic test results, follow-up,
and completion of screening services.
c. If the enrolled participant has an
abnormal colorectal cancer screening test, the health care provider or local
coordinator shall provide to the participant a comprehensive referral directing
the participant to appropriate additional diagnostic or treatment services.
When the results of a screening test are positive, the local coordinator shall
work with the participant and enrolled health care provider to schedule a
colonoscopy.
d. The local program
coordinator shall follow up with the provider to obtain results if not provided
in a timely manner.
e. IGS program
staff shall follow up with the local program coordinator if results have not
been entered in the IGS data system in a timely manner.
(4) If treatment services are needed, the
participant's health care provider may perform a consultation in order to
educate the participant about treatment options. If more than two office visits
are warranted for a participant throughout the screening cycle, subsequent
office visits must be authorized by IGS program staff.
(5) IGS program staff shall use quality
assurance and process improvement techniques including use of established
standards, systems, policies and procedures to monitor, assess and identify
practical methods for improvement of the IGS program and its components.
Quality assurance and process improvement are integral components of the IGS
program and contribute to program success. As part of the vision, to reduce
morbidity and mortality from colorectal cancer, high-quality, timely
participant services are essential. IGS program requirements and monitoring
activities shall include:
a. Professional
licensure and accreditation. Health facilities and health care providers must
be currently licensed or accredited to practice in the state of Iowa.
b. Reporting standards. Radiological,
laboratory and pathology and other results must be reported according to
national standards.
c. Standards
for adequacy of follow-up. Data reports shall track appropriate and timely
short-term, diagnostic and rescreening services.
d. A case management services approach. Local
program staff shall follow the participants through the colorectal cancer
screening process from the first contact to final diagnosis and as needed for
referral to treatment and patient navigation services. Local program staff
shall be responsible for documenting these activities as described in paragraph
10.3(2)"d."
e.
Accurate data collection and documentation. Contractor calls are conducted with
staff to provide technical assistance, give feedback on program performance,
evaluate case management process and if needed conduct a walk-through of
current services to provide feedback.
f. Program evaluation.
(6) The IGS program and contracted local
program staff shall provide in-reach education and recruitment that involve the
systematic design and delivery of clear and consistent messages about
colorectal cancer (CRC) and the benefits of early detection using a variety of
methods and strategies. In-reach activities shall focus on men and women who
have never or rarely been screened for CRC and shall work toward the removal of
barriers to screening (e.g., transportation) through collaborative activities
with other community organizations.
(7) The IGS program shall conduct
surveillance utilizing continuous, proactive, timely and systematic collection,
analysis, interpretation and dissemination of colorectal cancer screening
prevalence, survival and mortality rates. Studies shall be conducted utilizing
minimum data elements and other data sources to establish trends of disease,
diagnosis, treatment, and research needs. IGS program planning, implementation
and evaluation shall be based on the data.
(8) Evaluation shall be conducted through
documentation of services, operation processes at the state and local program
levels and outcomes of the IGS program.
