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

​We want to remind our providers that Independence Blue Cross (IBX) 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.* 

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 colonos​​copy or flexible sigmoidoscopy that meets the preventive criteria usin​g 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:

  • appro​priate diagnostic CPT® procedure code + Modifier PT

OR

  • ap​propriate diagnostic CPT procedure code + Modifier 33

OR

  • appropriate diagnostic CPT proce​dure code + ICD-10 code Z12.11

OR

  • appro​priate 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 recommenda​tions.​

​

​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 #00.06.02aq: 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, please refer to Medical Policy #11.03.12t: Colorectal Cancer Screening.

To view these policies, go to the 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) and consumer commercial plans include a Preventive Plus feature that requires members to see a Preventive Plus 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 non-Preventive Plus providers. Small group and consumer commercial members who live outside of our five-county service area (i.e., Bucks, Chester, Delaware, Montgomery, and Philadelphia counties) and contiguous counties (i.e., counties that surround the IBX five-county service area) may obtain a Preventive ​​colonoscopy screening from any in-network provider at $0 cost-sharing.

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