FLASH: Coding for Colorectal Cancer Screening

Health Alliance™ is committed to continuous improvement. As a result, a team of Medical Directors and coding experts have adjusted our processes to accurately activate cost-share waiver and proper provider reimbursement for our Colorectal Screening Tests that meet the requirements of a preventative service as outlined below.

Accurate claims billing is essential to receiving correct payment for a preventive care service and for waiving cost-share for our members. Health Alliance follows United States Preventive Services Task Force (USPSTF) guidelines and Affordable Care Act (ACA) requirements that indicate 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 an asymptomatic individual for colorectal cancer, it is considered preventive, regardless of the exam findings.

Please note, this is not a guarantee of benefits or evidence of coverage, please refer to the member’s plan benefits for availability of benefits and cost share waiver. Members’ benefits may vary according to benefit design; therefore, member benefit language should be reviewed before applying the terms of this provider flash.

Stool tests

Stool tests are at-home tests that we cover as preventative following the criteria listed below.

• Fecal immunochemical test (FIT) and Fecal Occult Blood Tests (FOBT) can be billed as preventative using the following procedure codes: 82270, 82274, or G0328.

These tests are covered annually starting at age 45 for most of our Commercial members; starting at age 50 for Medicare Members and for Self-Funded members, please see their specific plan details.

• Cologuard Stool DNA Test can be coded using the following procedure code: 81528. We are no longer requiring specific ICD-10 codes to activate the patient cost share waiver. 

Stool DNA tests are only covered for screening purposes; symptomatic members are not covered for this test, it is U.S. Food, and Drug Administration (FDA) approved for average-risk individuals only. The test is covered once every 3 years for ages 45–75 for most of our Commercial members; ages 50-85 for Medicare Members and for Self-Funded members please see their specific plan details.

If the patient gets a FIT or Cologuard test that comes back positive and they need a follow-up colonoscopy, the colonoscopy must be performed within 160 days of the FIT or Cologuard test and to be covered with no cost share for the member, one of the following ICD-10 codes must be included on the colonoscopy claim: 

Z12.10 – Encounter for screening for malignant neoplasm of intestinal tract, unspecified
Z12.11 – Encounter for screening for malignant neoplasm of colon
Z12.12 – Encounter for screening for malignant neoplasm of rectum
Z80.0 – Family history of malignant neoplasm of digestive organs

Colonoscopy

Colonoscopies are covered for screening once every 10 years from ages 45–75 for most of our average risk Commercial members. For high-risk Commercial members under age 45 please see specific plan details. Medicare members are allowed screening colonoscopies once every 2 years for high-risk patients and once every 10 years for average risk patients and for Self-Funded members please see their specific plan details.

• The following procedure codes can be billed as preventative allowing patient waiver of cost share using the following codes: G0105, G0120, G0121, 45378, 45380, 45384, 45385, or 45388.

To activate the cost share waiver for the patients’ preventative colonoscopy, you will need to append one of the following ICD-10 Diagnosis codes on the claim:

Z12.10 – Encounter for screening for malignant neoplasm of intestinal tract, unspecified
Z12.11 – Encounter for screening for malignant neoplasm of colon
Z12.12 – Encounter for screening for malignant neoplasm of rectum
Z80.0 – Family history of malignant neoplasm of digestive organs

Per CMS guidelines, add the -PT modifier to the CPT codes above to any scheduled screening colonoscopy converted into a diagnostic or therapeutic colonoscopy. The PT modifier is not, however, required on routine screening colonoscopy to activate the cost share waiver, only one of the four Diagnosis codes above.

Sigmoidoscopy

Sigmoidoscopies can be done every 5 years from ages 45–75 for our Commercial members; every 4 years age 50 and older for Medicare Members and for Self-Funded members please see their specific plan details.

• The following procedure codes can be billed as preventative allowing patient waiver of cost share using the following codes: G0104, G0106, 45330, 45331, 45338.

To activate the cost share waiver for the patients’ preventative sigmoidoscopy, you will need to append one of the following ICD-10 Diagnosis codes on the claim:

Z12.10 – Encounter for screening for malignant neoplasm of intestinal tract, unspecified
Z12.11 – Encounter for screening for malignant neoplasm of colon
Z12.12 – Encounter for screening for malignant neoplasm of rectum
Z80.0 – Family history of malignant neoplasm of digestive organs

Per CMS guidelines, add the -PT modifier to the CPT codes above to any scheduled sigmoidoscopy converted into a diagnostic or therapeutic sigmoidoscopy. The PT modifier is not, however, required on routine screening sigmoidoscopy to activate the cost share waiver, only one of the four Diagnosis codes above.

Virtual Colonoscopies

A screening CT colonography will require prior authorization through eviCore and will need to meet clinical criteria to be covered every 5 years from ages 45-75 for most of our Commercial members; for Medicare members the test is not covered and for Self-Funded members please see their specific plan details.

• The following procedure code can be billed as preventative allowing patient waiver of cost share using the following code: 74263.

If you have any questions, please contact your provider relations specialist. To check specific Self-Funded member requirements, you can access their benefits through the online portal or by calling our Self-Funded Customer Solutions Team at (800) 851-3379 ext. 28923.