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Processing Claims for Preventive Colonoscopies Now Automated

October 15, 2012

Processing for preventive colonoscopy claims with modifiers PT and 33 is now automated for Blue Cross and Blue Shield of Oklahoma (BCBSOK). This new automated claims processing demonstrates BCBSOK’s commitment to make changes to effectively implement the Affordable Care Act (ACA) Preventive Care Services provision.

The Current Procedural Terminology (CPT®) modifier 33 became effective Jan. 1, 2011. BCBSOK had manually processed claims submitted with this modifier while automation was being completed.

ACA requires that preventive services such as diagnostic colonoscopies be covered without member cost-sharing when the member is covered by a non-grandfathered health care plan. That means the preventive service must be covered with no coinsurance, deductible or copay when the patient covered under a non-grandfathered BCBSOK health plan uses health care professionals in the BCBSOK network.  

Accurate claims billing is essential to receiving correct payment for a preventive care service like a diagnostic colonoscopy.  The initial reason a procedure was performed determines whether it 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 ACA requirements. That procedure should be billed using the applicable new CPT modifier 33. However, the CPT modifier 33 does not apply to non-preventive colonoscopies, such as those done to evaluate or follow up on signs, symptoms or pre-existing conditions. 

Health care providers should already be using the new CPT modifier 33 that became effective Jan. 1, 2011. This modifier alerts us and others who pay health insurance claims that the service was provided as preventive care, and that deductibles, copays and coinsurance do not apply. 

Tips on Using Modifiers for Preventive Services

Sometimes it can be difficult to know when to use which modifiers. Here are some tips that may help:

  • If the purpose of the procedure is to screen for colorectal cancer and the service becomes diagnostic during the procedure, both modifier PT and 33 may be used.
  • Modifier 33 can be used alone when the service remains preventive throughout the procedure.
  • Modifier 33 is not used for non-preventive colonoscopies or other non-preventive procedures.
  • At least one of the preventive modifiers must be used in order for the colonoscopy claim to pay as preventive.
  • A colonoscopy procedure will pay at the no-cost sharing benefit level as long as modifier 33 is used alone or in combination with the PT modifier (PT +33).
  • Colonoscopies not billed with one of the preventive modifiers will not be paid as a preventive screening.

Frequently Asked Questions about Preventive Colonoscopies

1.       What colonoscopy procedures is BCBSOK defining as preventive?

A service associated with a screening colonoscopy 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 – as long as 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 part of the screening colonoscopy?

A service that is directly related to a screening colonoscopy is considered to be part of the screening colonoscopy:

  • Colonoscopy screening procedure
  • Pathology services
  • Anesthesiology (if necessary)
  • Outpatient facility fee

3.       What if a procedure has already been performed and improperly
          coded and the member has paid a share of the cost?

If the member or provider calls or writes to ask why the procedure was not paid without cost sharing, the Customer Advocate will be authorized to make an adjustment and reimburse the provider, if appropriate. This will be done through the normal “Explanation of Benefits” process.

4.       Will BCBSOK adjust a claim for a colonoscopy?

There are a number of factors that could impact the way BCBSOK will reimburse for a colonoscopy procedure. Reasons that may lead to the claim being paid with member cost-sharing include number of visits; age limits; use of a non-network provider; procedure billed as diagnostic or medical; symptoms or history.

If a member advises that a colonoscopy was intended to be preventive, BCBSOK will research claims history and adjust the claim when it represents the first one on record for the member. The provider may be called if a claims search does not find a preventive diagnosis on the corresponding date of service.

5.       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, BCBSOK 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 – as long as 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.

CPT copyright 2010 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

For more information about the USPSTF recommendation on screening for colorectal cancer see http://www.uspreventiveservicestaskforce.org/uspstf/uspscolo.htm .

This material is for informational purposes only and is not the provision of legal advice. If you have any questions regarding the law, you should consult with your legal advisor.

Verification of eligibility and/or benefit information 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 applicable on the date services were rendered.