Recently, the American Cancer Society (ACS) updated its guidelines for colorectal cancer (CRC) screening for average-risk-level adults. The ACS now recommends that adults ages 45 years and older with an average-risk level for CRC undergo regular screening with either a high?sensitivity stool?based test or a structural (visual) examination. Earlier guidelines recommended that CRC screening for average-risk-level patients begin at age 50.
As of July 1, 2018, AmeriHealth New Jersey covers CRC screening and related services for average-risk-level adults beginning at age 45 with $0 member cost-sharing (i.e., copayments, coinsurance, and deductibles). For more information on the updated ACS CRC screening guidelines, refer to the previously published article, Revised guidelines for colorectal cancer screening for average?risk-level AmeriHealth New Jersey adult members.
Below are updated guidelines for billing a preventive colonoscopy or flexible sigmoidoscopy.
Guidelines for billing for a preventive colonoscopy or flexible sigmoidoscopy
AmeriHealth New Jersey is consistent with the requirements of the Affordable Care Act by covering certain CRC screening tests without member cost-sharing when commercial members use an in-network provider.
Currently, we follow the U.S. Preventive Services Task Force (USPSTF) screening recommendations for CRC. In addition, and in compliance with New Jersey mandates, CRC screening tests are also covered without member cost-sharing in accordance with the ACS recommendations. ACS recommends CRC screening for individuals at average risk, increased risk, and high risk. ACS recommendations provide a screening schedule dependent on the type of risk.
The following scenarios provide direction on how to properly apply codes when billing for preventive CRC cancer screenings and identify the applicable member cost-share requirements on or after July 1, 2018:
| Billing scenario | Coding & billing requirements and member cost-share |
|---|
Scenario 1: Patient receives a standard screening, such as a colonoscopy or flexible sigmoidoscopy that meets the preventive criteria using an in-network provider | Coding & billing requirements: - Appropriate screening HCPCS code
Member cost-share: |
Scenario 2: Patient receives colonoscopy or flexible sigmoidoscopy that meets the preventive criteria, using an in-network provider, which converts from a screening to a diagnostic service | Coding & billing requirements: - Appropriate diagnostic CPT? procedure code + Modifier PT
OR - Appropriate diagnostic CPT procedure code + Modifier 33
OR - Appropriate diagnostic CPT procedure code + diagnosis code Z12.11
OR - Appropriate diagnostic CPT procedure code + diagnosis code Z12.12
Member cost-share: |
Scenario 3: Patient receives a medically-necessary esophagogastroduodenoscopy (EGD) on the same day as a preventive CRC screening test | Coding & billing requirements: - Appropriate screening HCPCS code
OR - Appropriate diagnostic CPT procedure code + Modifier PT
OR - Appropriate diagnostic CPT procedure code + Modifier 33
OR - Appropriate diagnostic CPT procedure code + diagnosis code Z12.11
OR - Appropriate diagnostic CPT procedure code + diagnosis code Z12.12
AND - Appropriate EGD code
Member cost-share: - No, for the preventive colonoscopy or flexible sigmoidoscopy.
- Yes, for the EGD. Refer to the specific terms of the member?s benefit plan.
|
Scenario 4: Patient receives a CRC screening test that is not included in the USPSTF recommendations or the ACS recommendations | Coding & billing requirements: - Appropriate diagnostic CPT procedure code
- Subject to medical-necessity
Member cost-share: - Yes. Refer to the specific terms of the member?s benefit plan.
|
Note: If the appropriate billing codes are not used, the member will be billed a cost-share.
Learn more
For more information and a complete list of medical necessity criteria for Preventive CRC screening, please refer to commercial Medical Policy #00.06.02v: Preventive Care Services, which became effective July 1, 2018.
For more information on medical necessity criteria for CRC screening that is not included in the USPSTF recommendations, please refer to commercial Medical Policy #11.03.12o: Colorectal Cancer Screening.
To view these policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, then select Commercial and type the policy name or number in the Search field.
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