Processing claims for preventive colonoscopies now automated
The Current Procedural Terminology (CPT®) modifier 33 became effective Jan. 1, 2011. BCBSNM 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 BCBSNM health plan uses health care professionals in the BCBSNM 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:
1. What colonoscopy procedures is BCBSNM 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?
3. What if a procedure has already been performed and improperly coded and the member has paid a share of the cost?
4. Will BCBSNM adjust a claim for a colonoscopy?
5. What if a problem is found during the colorectal screening? Does it change the way the claim is paid?
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.
Blue Review • October 2012 • bcbsnm.com