AmeriHealth New Jersey 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. Our billing requirements for a preventive colonoscopy or flexible sigmoidoscopy have recently changed.

Currently, we follow the United States Preventive Services Task Force (USPSTF) screening recommendations for colorectal cancer. In addition, and in compliance with New Jersey mandates, colorectal cancer screening tests are also covered without member cost-sharing in accordance with the American Cancer Society (ACS) recommendations. ACS recommends colorectal cancer screening for individuals at average risk, increased risk, and high risk. ACS recommendations provide a screening schedule dependent on the type of risk.

Billing for a preventive colonoscopy or flexible sigmoidoscopy

When billing for a colonoscopy or flexible sigmoidoscopy that meets the preventive criteria and the procedure does not convert 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 New Jersey has expanded the billing requirements to accept an additional Modifier 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 code must be reported with one of the following: Modifier PT or Modifier 33 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

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
  OR Modifier 33
  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 colorectal cancer screening test that is not included in the USPSTF recommendations or the ACS 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 but is included in the ACS 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.

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