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 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) 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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