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Preventive Coverage of Colonoscopy Following a Positive Non-invasive Stool-based Screening Test or Direct Visualization Test for Independence Commercial Members


Policy Impacted


00.06.02

Purpose

The purpose of this communication is to convey our current coverage position regarding coverage of a screening colonoscopy following a positive non-invasive stool-based screening test or direct visualization test for Independence Commercial members. 

Background

On January 10, 2022, the Departments of Labor, Health and Human Services (HHS), and the Treasury jointly issued guidance indicating that,​ a follow-up colonoscopy after a positive non-invasive stool-based screening test or direct visualization test is considered an important part of the preventive screening, without which the screening would not be ​complete. Therefore, the follow-up colonoscopy is considered a preventive service.  

Coverage Statement

For those who are eligible for preventive colorectal cancer screening in accordance with the Preventive Care Services policy, a follow-up colonoscopy after a positive non-invasive stool-based screening test or direct visualization test is considered an important part of the preventive screening. Therefore, a follow-up colonoscopy after a positive non-invasive stool-based screening test or direct visualization test​ is considered a preventive service.  

BILLING REQUIREMENTS

When all of the preventive criteria are met, a follow-up screening colonoscopy is​ only reimbursed when reported with the eligible procedure codes, diagnosis codes, and the appropriate modifier (modifier 33 or PT). ​

Coding

CURRENT PROCEDURAL TERMINOLOGY (CPT) CODES

THE FOLLOWING CODES REPRESENT COLONOSCOPY:
The following codes will only be considered preventive when a screening colonoscopy meets all of the preventive criteria and is reported with modifier PT , modifier 33, or ICD-10 diagnosis code Z12.11 or Z12.12.

44388 

44389 

44392 

44394 

44401 

44403 

44406 

44407 

45378 

45380 

45381 

45384 

45385 


45388 

45390 

 


HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS) CODES
 
THE FOLLOWING CODES REPRESENT COLONOSCOPY:


G0105 Colorectal cancer screening; colonoscopy on individual at high risk

G0121 Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk

 
MODIFIERS


PT Colorectal cancer screening test, converted to diagnostic test or other procedure

33 Preventive Services



6/14/2022