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.
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
It is important to use the following codes and modifiers when billing for a preventive colorectal cancer screening:
- 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 previously communicated, effective
January 1, 2017,Modifier PT must be appended to the appropriate diagnostic CPT®procedure 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 diagnostic CPT procedure 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.
- As previously communicated, effective
July 1, 2017,AmeriHealth New Jersey expanded the billing requirements to accept additional modifiers in conjunction with appropriate diagnostic CPT procedure 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 diagnostic CPT procedure code must be reported with
one of the following to indicate a preventive service: Modifier PT or Modifier 33.
If the appropriate billing requirements are not used, the member will be billed a cost-share.
Patient scenarios
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 procedure 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 procedure code + Modifier PT
OR
- appropriate diagnostic CPT procedure code + Modifier 33
Member cost-share: |
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
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 responsible 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 #00.06.02y: Preventive Care Services.
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 #11.03.12q: Colorectal Cancer Screening.
To view these policies, visit our Medical Policy Portal. Select Accept and Go to Medical Policy Online, then type the policy name or number in the Search field.
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