TitleWeb Cost-sharing and billing requirements for Preventivecolorectal cancer screening
Professional; Facility
October 31, 2016
Page Content Independence 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 members enrolled in a commercial plan, 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 will be
posted as a Notification on November 1, 2016, and will become effective on
January 1, 2017.
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 #11.03.12l: Colorectal Cancer Screening for more
information.
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.
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.
Reminder: $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.
New billing requirement
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.
*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 2015 American Medical
Association. All rights reserved. CPT is a registered trademark of the American
Medical Association.
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