Accurate claims billing is essential to receiving correct payment for a preventive care service like a diagnostic colonoscopy. The initial reason a procedure was performed determines whether it is covered without member cost-sharing. For example, when the initial reason for a colonoscopy is to screen for colorectal cancer, it is considered preventive under the United States Preventive Services Task Force (USPSTF) guidelines that drive Affordable Care Act (ACA) requirements. That procedure should be billed using the applicable Current Procedural Terminology (CPT®) modifier 33. However, the CPT modifier 33, does not apply to non-preventive colonoscopies, such as those done to evaluate or follow up on signs, symptoms or pre-existing conditions.
For HealthSelectSM of Texas, Consumer Directed HealthSelectSM of Texas, HealthSelectSM and Consumer Directed HealthSelectSM Out-of-State, the prior authorization requirement is waived for preventive colonoscopies performed by in-network providers when the intent of the procedure is preventive and billed with modifier 33, regardless of the findings.
Tips on Using Modifiers for Preventive Services
Sometimes it can be difficult to know when to use which modifiers. Here are some tips that may help:
- If the purpose of the procedure is to screen for colorectal cancer and the service becomes diagnostic during the procedure, modifier 33 may be used.
- Modifier 33 is not used for non-preventive colonoscopies or other non-preventive procedures.
- A colonoscopy procedure will process at the no-cost sharing benefit level as long as modifier 33 is present.
- Colonoscopies not billed with one of the preventive modifiers will not be processed as a preventive screening.
Frequently Asked Questions about Preventive Colonoscopies
1. What colonoscopy procedures is Blue Cross and Blue Shield of Texas (BCBSTX) defining as preventive?
A service associated with a screening colonoscopy must pay at the preventive benefit level. If a procedure is billed as a screening, colonoscopy benefits will be applied as preventive based on the intent of the test and not on the findings. If a problem is found during the screening and a procedure is performed to address the problem (such as polyp removal), the claim will still be paid as preventive with no cost sharing – if it has been billed with modifier 33. If the procedure is not billed as preventive, it will not be paid as a preventive screening.
2. What services are considered part of the screening colonoscopy?
- Colonoscopy screening procedure
- Pathology services
- Anesthesiology (if necessary)
- Outpatient facility fee
A service that is directly related to a screening colonoscopy is part of the screening colonoscopy:
3. Will BCBSTX adjust a claim for a colonoscopy?
If a member advises that a colonoscopy was intended to be preventive, BCBSTX will research the claims history and potentially adjust the claim, if applicable. There are several factors that could impact the way BCBSTX will reimburse for a colonoscopy procedure. Reasons that may lead to the claim being paid with member cost-sharing include the number of visits; age limits; use of a non-network provider; procedure billed as diagnostic or medical; symptoms or history.
The provider may need to submit a corrected claim if they did not bill the colonoscopy as preventive when, in fact, it was a preventive procedure.
4. What if a problem is found during the colorectal screening? Does it change the way the claim is paid?
If a procedure is billed as a preventive screening, BCBSTX will assume that colonoscopy benefits should be applied based on the intent of the test and not on the findings. If a problem is found during the screening and a procedure is performed to address the problem (such as polyp removal), the claim will still be paid as preventive with no member cost sharing – if it has been billed using the appropriate preventive modifiers. If the procedure is not billed as preventive, it will not be paid as a preventive screening.
5. For Texas plans that include a prior authorization requirement, how are colonoscopies handled?
Providers should check eligibility and benefits to verify through Availity® or their preferred vendor for the current preauthorization/prior authorization requirements to determine if authorization is required for colonoscopies.
CPT copyright 2018 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.
This material is for informational purposes only and is not the provision of legal advice. If you have any questions regarding the law, you should consult with your legal advisor.
Verification of eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered.