Beginning January 1, 2017, when billing for a colonoscopy or flexible sigmoidoscopy that converts from a screening to a diagnostic service, a PT modifier must be appended to the appropriate diagnostic CPT^® code to indicate the service turned into a diagnostic procedure.

Additionally, when a medically necessary esophagogastroduodenoscopy (EGD) is performed on the same day as a Preventive colorectal cancer screening test (e.g., colonoscopy), it is subject to applicable member cost-sharing.

$0 cost-sharing for related screening services

No member cost-sharing is required for the following services when associated with a Preventive colorectal cancer screening procedure, when the criteria outlined in the Preventive Care Services policy are met:

• prescription bowel preparation medication for flexible sigmoidoscopy, colonoscopy, or CT colonography;
• pre-procedure consultation visit for flexible sigmoidoscopy, colonoscopy, or CT colonography;
• anesthesia associated with flexible sigmoidoscopy or colonoscopy;
• pathology associated with flexible sigmoidoscopy or colonoscopy.

AmeriHealth is consistent with the requirements of the Affordable Care Act by covering certain colorectal cancer screening tests without member cost-sharing (i.e., copayments, coinsurance, and deductibles) when using an in-network provider.* Currently, the United States Preventive Services Task Force (USPSTF) recommends screening for colorectal cancer in adults beginning at age 50 and continuing until age 75 using one of the following:

• fecal occult blood testing
• highly sensitive fecal immunochemical testing (FIT)
• CT colonography
• stool DNA testing (alone or combined with FIT)
• flexible sigmoidoscopy
• colonoscopy
• barium enema

For AmeriHealth Pennsylvania members, when the colorectal cancer screening tests identified above are billed, they will be processed as a Preventive service based on the frequency and age recommendations described by the USPSTF and outlined in Attachment A of Medical Policy #00.06.02s: Preventive Care Services. This policy, which will become effective on January 1, 2017, is being updated to clarify the cost-sharing differences for AmeriHealth Pennsylvania and AmeriHealth New Jersey members.

Please note that colorectal cancer screening tests that are not included in the USPSTF recommendations will be subject to medical necessity and member cost-sharing, based on the terms of the member?s benefit plan. Refer to Medical Policy #11.03.12m: Colorectal Cancer Screening for more information. This policy is currently posted as a Notification and will become effective on January 1, 2017.

To access these policies, visit our Medical Policy Portal and select Accept and Go to Medical Policy Online. Then select Commercial and type the policy name or number in the Search field.

*Small group (1-50) commercial plans in Pennsylvania include a site of service differential benefit that requires members to see a non-hospital based Preventive colonoscopy provider and meet the Preventive criteria for colonoscopy screenings to be covered with $0 cost-sharing; costsharing will apply when members have colonoscopy screenings performed by an in-network provider other than a non-hospital based Preventive colonoscopy provider. Note: The site of service differential benefit does not apply to members whose employer is located outside of Bucks, Chester, Delaware, Montgomery, and Philadelphia counties in Pennsylvania, and their adjacent counties.

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