Claims & Billing
Cost-sharing and billing requirements for preventive colonoscopy and flexible sigmoidoscopy services

​​We want to remind our providers that AmeriHealth 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 commercial members use an in-network provider.*

Review the following patient scenarios for direction on how to properly apply codes when billing for preventive colorectal cancer screenings and identify the applicable member cost-share requirements:

​​​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:

  • $0

​​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:

  • ​$0

​​Scenario 3:
Patient receives a medically necessary esophagogastroduodenoscopy (EGD) on the same day as a colorectal cancer screening that meets preventive criteria.

​Coding & billing requirements:

  • appropriate screening HCPCS procedure 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:

  • $0 for the preventive colonoscopy or flexible sigmoidoscopy.

  • ​The member is responsible for a cost-share for the EGD. Refer to the specific terms of the member's benefit plan.

​​Scenario 4: 

Patient receives a colorectal cancer screening that is not included in the USPSTF recommendations.​

​Coding & billing requirements:

  • appropriate diagnostic CPT procedure code

  • subject to medical necessity​

​Member cost-share:

  • ​The member is res​ponsible for a cost-share. Refer to the specific terms of the member’s benefit plan.

​

Learn more

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

For more information on medical necessity criteria for colorectal cancer screening that is not included in the United States Preventive Services Task Force (USPSTF) recommendations but is included in the American Cancer Society recommendations, please refer to Medical Policy #11.03.12t: Colorectal Cancer Screening.

To view these policies, visit our Medical Policy Portal. Select Commercial, 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.

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