AmeriHealth 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, AmeriHealth 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:

• $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 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:

• $0

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, 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.

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