Independence 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.*
Our billing requirements for a preventive colonoscopy or flexible sigmoidoscopy
have recently changed.
Billing for a preventive colonoscopy or
flexible sigmoidoscopy
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 covert to a diagnostic
service, report the appropriate HCPCS code.
As of January 1, 2017, Modifier PT must be appended to the
appropriate diagnostic CPT® code when billing for a colonoscopy
or flexible sigmoidoscopy that meets the preventive criteria and does
convert from a screening to a diagnostic service. When appended to the
appropriate CPT 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.
Effective July 1, 2017, Independence has expanded the
billing requirements to accept additional Modifiers and ICD-10 codes in
conjunction with appropriate CPT 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 CPT must be
reported with one of the following: Modifier PT, Modifier 33,
or ICD-10 diagnosis codes Z12.11 or Z12.12 to indicate a preventive
service.
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.
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 code + Modifier PT
OR
- Appropriate diagnostic CPT code + Modifier 33
OR
- Appropriate diagnostic CPT code + ICD-10 code Z12.11
OR
- Appropriate diagnostic CPT code + ICD-10 code Z12.12
Member cost-share:
Scenario 3: Patient receives a medically-necessary
esophagogastroduodenoscopy (EGD) on the same day as a preventive colorectal
cancer screening test
Coding & billing requirements:
- Appropriate screening HCPCS code
OR
- Appropriate diagnostic CPT code + Modifier PT, Modifier 33, ICD-10 code
Z12.11, or ICD-10 code Z12.12
- 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 colorectal cancer screening
test that is not included in the USPSTF recommendations
Coding & billing requirements:
- Appropriate diagnostic CPT 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 requirements 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 colorectal cancer screening, please refer to Medical Policy
#00.06.02t: Preventive Care Services, which became effective July 1,
2017.
For more information on medical necessity criteria for colorectal cancer
screening that is not included in the USPSTF recommendations, please refer to
Medical Policy #11.03.12n: Colorectal Cancer Screening.
To view these policies, go to the 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) and consumer commercial plans include
a Preventive Plus feature that requires members to see a Preventive Plus
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 non-Preventive Plus providers.
Small group and consumer commercial members who live outside of our five-county
service area (i.e., Bucks, Chester, Delaware, Montgomery, and Philadelphia
counties) and contiguous counties (i.e., counties that surround the
Independence five-county service area) may obtain a Preventive colonoscopy
screening from any in-network provider at $0 cost-sharing.
CPT copyright 2016 American Medical Association. All
rights reserved. CPT is a registered trademark of the American Medical
Association.