23-537m Bill Preventive Colonoscopies with Correct Modifiers for No Cost Share Benefits
Date: 06/30/23
Ensure the correct modifier is used when billing for Colorectal Cancer Screenings (CRC)
Effective January 1, 2022, California Assembly Bill 342 increased access to colorectal cancer screening. The new state law removed out-of-pocket costs for patients needing colonoscopies after positive non-invasive colorectal cancer screening tests. It requires zero-dollar coverage for grade A or B preventive services recommended by the United States Preventive Services Task Force (USPSTF). The goal is to remove financial barriers and encourage the patient to proceed to the colonoscopy procedure soon after a positive screening result from a non-invasive colorectal screening test.
Note: The Affordable Care Act (ACA) does not apply to Medicare or Medi-Cal. Screening tests, billing and patient costs may vary dependent on coverage. It is important to review source preventive and billing rules and guidance prior to completing any screening test to determine if cost-share applies.
Coverage and billing requirements
- Coverage – Assembly Bill 342 expands coverage with no cost share for CRC as preventive services when billed with correct modifiers for the following:
- High sensitivity gFOBT or FIT every year
- sDNA-FIT (Cologuard) every 1 to 3 years
- CT colonography every 5 years
- Flexible sigmoidoscopy every 5 years
- Flexible sigmoidoscopy every 10 years plus FIT every year
- Colonoscopy screening every 10 years
- Age lowered – The USPSTF previously recommended screening for adults ages 50-75 years (recommendation A). The USPTSF now recommends offering screening to begin at age 45 years (recommendation B). Adults ages 76 to 85 should be selectively screened and the clinician consider the patient’s overall health, prior screening history, and preferences (recommendation C). Screening should be discontinued after age 85 years.
- Follow-on screenings – The follow-on colonoscopy after a positive result from a non-invasive stool test, flexible sigmoidoscopy, or CT colonography is a covered benefit when the correct preventive diagnosis code and modifier are used.
We urge providers to submit the correct billing requirements to avoid patient claim issues. Please refer to the billing requirements below.
Billing requirements
Providers must follow these billing requirements to avoid patient claim issues when billing for CRC for no cost share benefits.
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Line of business | Requirements |
|---|---|
Medi-Cal | Medi-Cal covers preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) without cost sharing. The Department of Health Care Services (DHCS) lists the reimbursable procedure codes, and appropriate diagnosis codes for covered preventive services within the DHCS Preventive Services policy (PDF). Modifier 33 – Add modifier 33 to a colorectal cancer screening for no cost sharing. Billing Example: CPT Code + Modifier 33 = $0 cost share for patient |
Additional information
Providers are encouraged to access the provider portal for real-time information, including eligibility verification, claims status, prior authorization status, plan summaries, and more.
If you have questions regarding the information contained in this update, contact CalViva Health at 888-893-1569.
This information applies to Physicians, Participating Physician Groups (PPGs), Hospitals, and Ancillary providers.
This information applies to Medi-Cal in Fresno, Kings and Madera counties.