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Claims and Eligibility

Preventive and Follow Up Colonoscopies

Accurate claims billing is essential to receiving correct payment for a preventive care service such as an initial colonoscopy, or a follow-up colonoscopy if the results of the initial colonoscopy, test or procedure are abnormal. As of Jan. 1, 2022, in compliance with Texas SB 1028, follow-up colonoscopies billed with applicable AMA diagnosis codes will be processed according to the appropriate preventative and follow up benefits for commercial members. (Government program members are excluded).

COLONOSCOPY TYPE	DESCRIPTION
INITIAL DIAGNOSTIC	An initial colonoscopy is covered without member cost-sharing. For example, when the initial reason for a colonoscopy is to screen for colorectal cancer, it is considered preventive under the United States Preventive Services Task Force (USPSTF) guidelines that drive Affordable Care Act (ACA) requirements.
APPLICABLE FOLLOW UP	Follow up colonoscopy if the results of the initial colonoscopy, test or procedure has an abnormality (i.e., Z08 & Z09 screening)

For HealthSelect^SM of Texas, Consumer Directed HealthSelect^SM of Texas, HealthSelect^SM and Consumer Directed HealthSelect^SM Out-of-State, the prior authorization requirement is waived for preventive colonoscopies performed by in-network providers when the intent of the procedure is preventive and billed with modifier 33, regardless of the findings.

Tips on Using Modifiers for Preventive Services

Here are some tips regarding the 33 modifier:

If the purpose of the procedure is to screen for colorectal cancer and the service becomes diagnostic during the procedure, or as a follow up colonoscopy due to abnormal results of an initial colonoscopy, test or procedure that has an abnormality, modifier 33 may be used.
Except as stated above, Modifier 33 is not used for non-preventive colonoscopies or other non-preventive procedures.
A colonoscopy procedure will process at the no-cost sharing benefit level as long as modifier 33 is present.
Colonoscopies not billed with one of the preventive modifiers will not be processed as a preventive screening.

Frequently Asked Questions about Preventive and Follow up Colonoscopies

1. What colonoscopy procedures is BCBSTX defining as preventive?

A service associated with a screening colonoscopy, or with a follow-up to an initial colonoscopy, test or procedure that has an abnormality, must pay at the preventive benefit level. If a procedure is billed as a screening, colonoscopy benefits will be applied as preventive based on the intent of the test and not on the findings. If a problem is found during the screening and a procedure is performed to address the problem (such as polyp removal), the claim will still be paid as preventive with no cost sharing – if it has been billed with modifier 33. If the procedure is not billed as preventive, it will not be paid as a preventive screening.

2. What services are considered related as part of the colonoscopy screening or a follow up colonoscopy to an initial that has an abnormality benefit?

Pathology servicesAnesthesiology (if necessary)
Outpatient facility fee

3. Will BCBSTX adjust a claim for a colonoscopy?

If a member advises that a colonoscopy was intended to be preventive, or as a result of a follow up colonoscopy to an initial colonoscopy, test or procedure that has an abnormality, BCBSTX will research the claims history and potentially adjust the claim, if applicable. There are several factors that could impact the way BCBSTX will reimburse for a colonoscopy procedure. Reasons that may lead to the claim being paid with member cost-sharing include the number of visits; age limits; use of a non-network provider; procedure not billed as diagnostic or follow up colonoscopy to an initial colonoscopy, test or procedure with an abnormality; or medical; symptoms or history.

The provider may need to submit a corrected claim if they did not bill the colonoscopy as preventive when, in fact, it was a preventive procedure.

4. What if a problem is found during the colorectal screening? Does it change the way the claim is paid?

If a procedure is billed as a preventive screening, BCBSTX will assume that colonoscopy benefits should be applied based on the intent of the test and not on the findings. If a problem is found during the screening and a procedure is performed to address the problem (such as polyp removal), the claim will still be paid as preventive with no member cost sharing – if it has been billed using the appropriate preventive modifiers. If the procedure is not billed as preventive, it will not be paid as a preventive screening.

5. For Texas plans that include a prior authorization requirement, how are colonoscopies handled?

Providers should check eligibility and benefits to verify through Availity^® or their preferred vendor for the current prior authorization requirements to determine if authorization is required for colonoscopies.