Physician 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 Physician Follow-up Colonoscopy Resources Jump to... Coding Correctly Unexpected Billing Questions 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 you, your fellow providers, and administrative staff know these changes. Commerical Plans and MedicaidMedicareAdd 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. Did You Know? 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 made aware of these changes. Learn More What happens if a patient receives an unexpected bill? Colonoscopy following a positive stool-based test: Patient should contact their insurance. Tell them the U.S. Department of Labor (DOL) put out new guidance that health plans and insurers “must cover and may not impose cost sharing with respect to a colonoscopy conducted after a positive non-invasive stool-based screening test” for plan or policy years beginning on or after May 31, 2022. See questions 6 (page 9) and 7 (page 12) of the DOL FAQ About Affordable Care Act Implementation. Screening colonoscopy when a polyp was removed: Patient should contact their insurance company. Tell them the U.S. Department of Health and Human Services (HHS) put out guidance that “the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure.” See question 5 of the HHS Affordable Care Act Implementation FAQs. Patients have a right to file a complaint with the State Insurance Commissioner. Patients also have a right to file a federal complaint with the Department of Health & Human Services for states without an external review process. PDF Resource Stay up-to-date about the latest developments in colorectal cancer screening and help your patients avoid surprise bills and with our PDF resource. Download it to gain access to essential information that will not only help you provide your patients with the best possible care but also assist them in navigating the complexities of the healthcare system. download toolkit Free Screening Poster Download, print, and display this screening poster in your patient rooms to encourage people to get a timely screening! Download poster Questions? Please reach out to Fight CRC at Advocacy@FightCRC.org with any questions. Back to Top