AmeriHealth is consistent with the requirements of the Affordable Care Act by covering certain colonoscopy and flexible sigmoidoscopy tests without member cost-sharing (i.e., copayments, coinsurance, and deductibles) when commercial members use an in-network provider.*

Billing for a preventive colonoscopy or flexible sigmoidoscopy

It is important to use the following codes and modifiers when billing for a preventive colorectal cancer screening:

• When billing for a colonoscopy or flexible sigmoidoscopy that meets the preventive criteria, as recommended by the United States Preventive Services Task Force (USPSTF), and the procedure does not convert to a diagnostic service, report the appropriate HCPCS code.
• As previously communicated, effective January 1, 2017,when billing for a colonoscopy or flexible sigmoidoscopy that meets the preventive criteria and does convert from a screening to a diagnostic service, Modifier PT must be appended to the appropriate diagnostic CPT^® procedure code. When appended to the appropriate diagnostic CPT procedure code, Modifier PT indicates the service began as a preventive service, but then converted into a diagnostic procedure. The service will still be considered preventive and no member cost-share should be collected.
• As previously communicated, effective July 1, 2017,AmeriHealth expanded the billing requirements to accept additional modifiers and ICD-10 codes in conjunction with appropriate diagnostic CPT procedure codes when billing for a preventive colonoscopy or flexible sigmoidoscopy that converts to a diagnostic procedure.
• When the preventive criteria for colorectal cancer screening are met and the screening converts to a diagnostic procedure, the appropriate diagnostic CPT procedure code must be reported with one of the following to indicate a preventive service: Modifier PT, Modifier 33, or ICD-10 diagnosis code Z12.11 or Z12.

If the appropriate billing requirements are not used, the member will be billed a cost-share.

Patient scenarios

The following scenarios provide direction on how to properly apply codes when billing for preventive colorectal cancer screenings and identify the applicable member cost-share requirements on or after July 1, 2017:

Learn more

For more information and a complete list of medical necessity criteria for Preventive colorectal cancer screening, please refer to Medical Policy #00.06.02y: Preventive Care Services.

For more information on medical necessity criteria for colorectal cancer screening that is not included in the USPSTF recommendations, please refer to Medical Policy #11.03.12q: Colorectal Cancer Screening.

To view these policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, then 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; cost-sharing will apply when members have colonoscopy screenings performed by 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.

CPT Copyright 2017 American Medical Association. All rights reserved. CPT^® is a registered trademark of the American Medical Association.