CurrentHumanaPolicy CP2010102

Screening Colonoscopy

This document describes Humana's claims payment and billing expectations for screening colonoscopies and screening colonoscopies that convert to diagnostic or therapeutic procedures for Medicare Advantage and Commercial members.

Policy Summary

PayerHumana

PolicyScreening Colonoscopy

Policy CodePolicy CP2010102

Change TypeNo material change

Effective DateCommercial: 2/2010; Medicare: 6/2009

Next Review Date

Key ActionWhen billing screening services, report a screening ICD diagnosis code as primary and a diagnostic/abnormal finding code as secondary and report modifiers PT and 33 when appropriate.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6/2009Medicare effective date

2/2010Commercial effective date

11/2018Review date

CP2010102Policy number

When a Screening Colonoscopy Converts to Diagnostic/Therapeutic

Screening-colonoscopy-to-diagnostic conversion criteria

Conditions under which Humana will still consider a procedure a screening despite conversion to diagnostic/therapeutic during same session:

ALL of the following must be met:

The member has a screening colonoscopy benefit.
Frequency requirement (ONE of):
- For commercial plans, another screening colonoscopy has not been allowed for a date of service during the previous 12 months.
- For Medicare Advantage plans, the charge is not for a service performed more frequently than allowed, with respect to the previously allowed colorectal cancer screening, by Original Medicare guidelines.

Policy Summary

PayerHumana

PolicyScreening Colonoscopy

Policy CodePolicy CP2010102

Change TypeNo material change

Effective DateCommercial: 2/2010; Medicare: 6/2009

Next Review Date

Key ActionWhen billing screening services, report a screening ICD diagnosis code as primary and a diagnostic/abnormal finding code as secondary and report modifiers PT and 33 when appropriate.

SourceLink

On This Page

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Modifiers and Frequency Rules

ModifiersModifier

Modifier PT	Colorectal cancer screening test converted to diagnostic test or other procedure
Modifier 33	Preventive services

Commercial frequency limit

Commercial frequency limitNo previously allowed screening colonoscopy for the date of service during the previous 12 months.

Applies toCommercial Humana plans (per policy).

Documentation requirementClaim must contain screening and diagnostic diagnosis codes supported by medical records when conversion occurs.

Medicare Advantage frequency

Medicare Advantage frequencyService must not be performed more frequently than allowed by Original Medicare guidelines.

Applies toHumana Medicare Advantage plans (per policy).

Related requirementClaim must contain screening and diagnostic diagnosis codes supported by medical records when conversion occurs.

Billing and Coding Expectations

Billing Rule

Billing and coding expectations for screening colonoscopy

When billing screening services, report an ICD diagnosis code that accurately describes the screening. If the service begins as a screening but converts to a diagnostic or therapeutic procedure during the same operative session, report the appropriate screening ICD diagnosis code as the primary diagnosis and the diagnostic or abnormal finding ICD diagnosis code as the secondary or subsequent diagnosis. For commercial plans, ensure another screening colonoscopy has not been allowed for a date of service during the previous 12 months; for Medicare Advantage, ensure the charge is not for a service performed more frequently than allowed by Original Medicare guidelines. Report modifiers PT and 33 when appropriate.

Report an ICD diagnosis code that accurately describes the screening.
If screening converts during the same session, list screening ICD code first and diagnostic/abnormal finding code second.
Commercial plans: no previously allowed screening colonoscopy for the date of service in the prior 12 months.
Medicare Advantage: service must not be performed more frequently than allowed by Original Medicare guidelines.
Report modifiers PT and 33 when appropriate.

Key Terms

Diagnostic

DefinitionDiagnostic: Service or test performed to determine why symptoms exist.

Use in policyApplied when a screening colonoscopy reveals inflamed tissue, abnormal growths, or ulcers requiring further evaluation or treatment.

DocumentationWhen screening converts to diagnostic during same session, report diagnostic/abnormal finding diagnosis code as secondary.

Modifier PT

Modifier PT definitionModifier PT: Colorectal cancer screening test converted to diagnostic test or other procedure.

Billing guidanceReport modifier PT when a screening colonoscopy converts to a diagnostic or therapeutic procedure during the same operative session.

Supporting claimEnsure claim contains both screening and diagnostic diagnosis codes and medical records support conversion.

Modifier 33

Modifier 33 definitionModifier 33: Preventive services.

Billing guidanceReport modifier 33 when appropriate for preventive screening colonoscopy services.

Use with conversionsWhen screening converts to diagnostic/therapeutic, report screening ICD code as primary and diagnostic code as secondary; report modifier 33 when appropriate.

Screening

Screening definitionScreening: Preventive service provided to an individual without apparent signs or symptoms for identifying or excluding undiagnosed illness, disease or condition.

Conversion scenarioIf screening results in diagnostic/therapeutic procedure during same session, Humana may still consider it a screening if policy conditions are met.

Billing expectationWhen conversion occurs, report screening ICD code as primary and diagnostic/abnormal finding ICD code as secondary; report modifiers PT and 33 when appropriate.