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 covers CRC screening and related services for average-risk-level adults beginning at age 45 with the applicable 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 Pennsylvania 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 is consistent with the requirements of the Affordable Care Act by covering certain colonoscopy and flexible sigmoidoscopy tests without member cost-sharing when commercial members use an in-network provider.*
Coverage of the tests is subject to the terms, conditions, and limitations of the member?s benefit plan. Therefore, all member benefits must be verified on the NaviNet? web portal through the Eligibility and Benefits Inquiry transaction.
The following scenarios provide direction on how to properly apply codes when billing for preventive CRC screenings and identify the applicable member cost-share requirements on or after July 1, 2018:
| Billing scenario | Ages 45-49 | Ages 50 and above |
|---|
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 procedure code
Member cost-share: - Yes. Refer to the specific terms of the member?s benefit plan.
| Coding & billing requirements: - Appropriate screening HCPCS procedure 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 + ICD-10 code Z12.11
OR - Appropriate diagnostic CPT procedure code + ICD-10 code Z12.12
Member cost-share: - Yes. Refer to the specific terms of the member?s benefit plan.
| Coding & billing requirements: - Appropriate diagnostic CPT procedure code + Modifier PT
OR - Appropriate diagnostic CPT procedure code + Modifier 33
OR - Appropriate diagnostic CPT procedure code + ICD-10 code Z12.11
OR - Appropriate diagnostic CPT procedure code + ICD-10 code Z12.12
Member cost-share: |
Scenario 3: Patient receives a medically-necessary esophagogastroduodenoscopy (EGD) on the same day as a CRC screening test that meets preventive criteria | 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 + ICD-10 code Z12.11,
OR - Appropriate diagnostic CPT procedure code + ICD-10 code Z12.12
AND - Appropriate EGD code
Member cost-share: - Yes. The colonoscopy or flexible sigmoidoscopy and the EGD are subject to cost-sharing. However, only one cost-sharing payment per provider per date of service is applied. The higher cost-sharing amount applies when the patient receives a medically-necessary EGD on the same day as a preventive CRC screening test. Refer to the specific terms of the member?s benefit plan.
| 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 + ICD-10 code Z12.11,
OR - Appropriate diagnostic CPT procedure code + ICD-10 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 Example: A patient received a CRC screening test at age 47. The applicable cost-sharing was applied. At age 51, this patient has a CRC screening test and expects $0 cost-sharing because he is over age 50. However, applicable cost-sharing is applied because the second CRC screening test does not meet the USPSTF recommendation for screening once every ten years. | 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.
| 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 U.S. Preventive Services Task Force (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.
*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.
NaviNet is a registered trademark of NaviNet, Inc.