Insurer Follow-up Colonoscopy Resources

Commercial, federal, and state plans that follow U.S. Preventive Services Task Force (USPSTF) guidance are legally required to provide full coverage for a follow-up colonoscopy after a positive or abnormal non-invasive stool-based test.

While this coverage is legally required, it also saves costs for insurers in the long run if prevention of colorectal cancer disease progression can happen through preventative testing means

Coding This Change Correctly

Due to the passage of the Affordable Care Act (ACA), Medicare and most third-party payers are required to cover services given an “A” or “B” rating by USPSTF without a copay or deductible, but the correct CPT and ICD-10-CM codes must be submitted to trigger coverage at 100% for the patient. Please ensure that your teams that process claims and appeals are aware of these changes.

Commerical Plans and MedicaidMedicare
Add modifier 33 to each CPT code submitted on the claim for commercial and Medicaid patients. If modifier 33 is not added, the colonoscopy will not be recognized as a screening service and the patient will be inappropriately billed.Use modifier KX with HCPCS code G0105 or G0121 for screening colonoscopy for patients following a non-invasive stool-based test for patients with Medicare. If polyps are removed, use the appropriate CPT code with modifier PT. Coinsurance applies when polyps are removed.

Complex Coding Case?

See the American Gastroenterological Association’s (AGA) coding guide for colorectal cancer screening to learn more, including what to do with complex coding cases.

“When I turned 50 my doctor recommended a non-invasive colorectal cancer screening test due to my busy lifestyle and inability to miss a day of work. I did the test and it came back positive. The day before my scheduled colonoscopy, I received a call telling me that I had to pay nearly $1,000 before they would perform the test. I almost didn’t go in, but thankfully I did because I was diagnosed with stage III colorectal cancer.”

Stage III colorectal cancer

Screening Pathways

There are two screening pathways depicted. All tests in Path B, including the follow-up colonoscopy, should now be covered by Medicare, ACA, and commercial plans.

Click here for a high-res version.

PDF Resource

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