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Colorectal Screening Claim Submission for Commercial Business Line

Audience: Physicians and facilities

We remind you that the Health Plan adheres to the U.S. Preventative Services Task Force (USPSTF) recommendation for colorectal cancer screening, which was updated on May 18, 2021, to include adults aged 45 to 49 years who are of average risk for colon cancer. 

The recommendation affirmed the following: “When non-invasive stool-based tests (e.g., guiac-based (gFOBT), immunochemical (FIT), multi-targeted stool DNA test or direct visualization screening tests (flexible sigmoidoscopy or virtual colonoscopy (CT colonography)) for colorectal cancer reveal abnormal results, follow up with colonoscopy is needed for further evaluation” to complete the screening spectrum.

Further guidance was issued on January 10, 2022 by the U.S. departments of Labor, Health and Human Services, and the Treasury noting: “The follow-up colonoscopy after a positive non-invasive stool-based screening test or direct visualization screening test is therefore required to be covered without cost sharing in accordance with the recommendations by the USPSTF and clarified in federal guidance.” 

Effective May 18, 2021, claims must be submitted with modifier 33 and the screening diagnosis code in the first position to ensure that the proper screening benefit is applied for follow-up colonoscopies. This applies to the Commercial line of business.

Coding Example:
6/1/21-non- invasive stool test - CPT 81528   ICD 10 CM - Z12.11
7/1/21-follow up colonoscopy - CPT 45378- 33 ICD 10 CM - Dx Z12.11

Colonoscopy bills submitted on or after May 18, 2021, without inclusion of modifier 33 or Dx Z12.11 can be resubmitted with a corrected claim if the service should have been billed originally as a screening procedure under the updated guidance. 

If you have questions, please contact your Provider Relations representative.

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