December 6, 2021
This information does not apply to self-funded Administrative Services Only (ASO), government programs (Medicare Advantage and Illinois Medicaid), Federal Employee Program® (FEP®) or BlueCard® out-of-area members.
Accurate claim coding is essential to receiving correct payment for a preventive care service, such as an initial diagnostic 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 Illinois House Bill 2653, follow-up colonoscopies billed with applicable American Medical Association (AMA) diagnosis codes will be processed according to the appropriate preventive and follow-up benefits for commercial fully insured Blue Cross and Blue Shield of Illinois (BCBSIL) members.
When the initial reason for a colonoscopy is to screen for colorectal cancer, it’s considered preventive under the United States Preventive Services Task Force (USPSTF) guidelines that drive Affordable Care Act (ACA) requirements. This initial colonoscopy is covered without member cost-sharing.
A follow-up colonoscopy may be necessary if the results of the initial colonoscopy, test or procedure show an abnormality (i.e., Z08 and Z09 screening). A colonoscopy that’s determined to be medically necessary by the ordering provider as a follow-up exam to the initial preventive screening is covered without member cost-sharing.
Prior authorization is not required for initial diagnostic or applicable follow-up colonoscopies performed by in-network providers when the intent of the procedure is preventive and the test is billed with modifier 33, regardless of the findings.
Using Modifier 33 for Preventive Services
Here are some modifier 33 tips and reminders:
- If the purpose of the procedure is to screen for colorectal cancer and the service becomes diagnostic during the procedure, or the procedure is a follow-up colonoscopy due to abnormal results of an initial colonoscopy, test or procedure, modifier 33 may be used.
- Except as stated above, modifier 33 should not be used for non-preventive colonoscopies or other non-preventive procedures.
- A colonoscopy procedure will process at the no-cost sharing benefit level for applicable members as long as modifier 33 is present.
- Colonoscopies billed without appropriate modifiers will not be processed as preventive screenings.
Frequently Asked Questions
Here are answers to some questions we’ve received from providers about preventive and follow-up colonoscopies:
What colonoscopy procedures is BCBSIL defining as preventive?
A service associated with a screening colonoscopy, or with a follow-up to an initial abnormal colonoscopy, test or procedure 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.
What services are considered related as part of the initial abnormal diagnostic or applicable follow-up colonoscopy?
- Professional fee (i.e., gastroenterology)
- Pathology services
- Anesthesiology (if necessary)
- Outpatient facility fee
Will BCBSIL adjust a claim for a colonoscopy?
If a member advises that a colonoscopy was intended to be preventive, or a follow-up colonoscopy to an initial abnormal colonoscopy, test or procedure, BCBSIL will research the claims history and potentially adjust the claim, if appropriate. There are several factors that could impact the way BCBSIL 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 abnormal colonoscopy, test or procedure; 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.
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, BCBSIL 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 modifier. If the procedure is not billed as preventive, it will not be paid as a preventive screening.
The information in this article is being provided for educational purposes only and is not the provision of medical care or advice. Physicians and other health care providers are encouraged to use their own best medical judgment based upon all available information and the condition of the patient in determining the best course of treatment. This material is for educational purposes only and is not intended to be a definitive source for coding claims. Health care providers are instructed to submit claims using the most appropriate code(s) based upon the medical record documentation and coding guidelines and reference materials. The fact that a service or treatment is described in this material is not a guarantee that the service or treatment is a covered benefit and members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any service or treatment is between the member and their health care provider.
Checking eligibility and/or benefit information and/or obtaining prior authorization or pre-notification is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, call the number on the member's ID card.