CurrentHumanaPolicy CP2010102

Screening Colonoscopy

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 products.

Policy Summary

PayerHumana

PolicyScreening Colonoscopy

Policy CodePolicy CP2010102

Change TypeNo material change

Effective DateFeb 1, 2010

Next Review DateNov 1, 2018

Key ActionWhen billing screening services, report an accurate screening ICD as primary and report diagnostic/abnormal finding ICD as secondary when the screening converts to diagnostic/therapeutic.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Medicare & CommercialApplies to

12 monthsCommercial lookback

Original MedicareMedicare reference

PT, 33Recommended modifiers

Coverage Criteria for Screening Colonoscopy Conversions

Screening-to-diagnostic conversion criteria

Conditions under which a screening colonoscopy that becomes diagnostic/therapeutic will still be considered a screening for claims purposes:

ALL of the following must be met:

Member has a screening colonoscopy benefit
The claim contains both a screening and a diagnostic (or abnormal finding) diagnosis code and the claim can be supported by medical records
AND either of the following frequency conditions:
- For commercial plans: another screening colonoscopy has not been allowed for a date of service during the previous 12 months

Policy Summary

PayerHumana

PolicyScreening Colonoscopy

Policy CodePolicy CP2010102

Change TypeNo material change

Effective DateFeb 1, 2010

Next Review DateNov 1, 2018

Key ActionWhen billing screening services, report an accurate screening ICD as primary and report diagnostic/abnormal finding ICD as secondary when the screening converts to diagnostic/therapeutic.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding, Frequency, and Modifier Guidance

Recommended modifiersModifier

PT	Modifier PT — colorectal cancer screening test converted to diagnostic test or other procedure
33	Modifier 33 — preventive services

Commercial screening frequency check

Commercial lookback periodNo other screening colonoscopy allowed for the date of service during the previous 12 months

Applicable productCommercial plans (per plan-specific benefits)

Supporting requirementClaim must contain both a screening and diagnostic diagnosis code and be supported by medical records

Benefit prerequisiteMember must have a screening colonoscopy benefit

Medicare Advantage frequency check

Medicare Advantage frequency ruleNot performed more frequently than allowed by Original Medicare colorectal cancer screening guidelines

Applicable productMedicare Advantage plans (subject to Original Medicare limits)

Supporting requirementClaim must contain both a screening and diagnostic diagnosis code and be supported by medical records

Benefit prerequisiteMember must have a screening colonoscopy benefit

Provider Billing and Documentation Actions

Billing Rule

Billing diagnosis reporting

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 in the same session, report the screening ICD diagnosis code as the primary diagnosis and the diagnostic/abnormal finding ICD code as the secondary diagnosis. Ensure the claim is supported by medical records when a screening converts to diagnostic/therapeutic service.

Report an ICD diagnosis code that accurately describes the screening.
If a screening converts to diagnostic/therapeutic procedure, list screening ICD as primary and diagnostic/abnormal finding ICD as secondary.
Claims converting to diagnostic/therapeutic procedures must be supported by medical records.

Billing Rule

Modifier reporting

Report modifier PT for colorectal cancer screening tests that are converted to diagnostic or therapeutic procedures. Report modifier 33 for preventive services when appropriate. Use these modifiers to indicate screening-to-diagnostic conversions and preventive service claims.

Modifier PT — Colorectal cancer screening test converted to diagnostic/other procedure.
Modifier 33 — Preventive services.

Documentation Required

Eligibility and frequency checks

Verify member eligibility and benefit frequency before performing or billing screening colonoscopy. Confirm the member has a screening colonoscopy benefit and check plan-specific frequency limits: commercial plans generally allow one screening colonoscopy per 12 months for converted services, while Medicare Advantage follows Original Medicare frequency rules. Ensure the claim includes both screening and diagnostic diagnosis codes (when applicable) and that documentation supports the conversion.

Confirm member has a screening colonoscopy benefit.
For commercial plans, another screening colonoscopy must not have been allowed for the same member within the previous 12 months (when applicable).
For Medicare Advantage, the service must not exceed Original Medicare frequency limits for colorectal cancer screening.
Ensure claims have appropriate screening and diagnostic ICD codes and supporting medical records.

Definitions

Diagnostic

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

ContextA screening colonoscopy that reveals inflamed tissue, abnormal growths, or ulcers and leads to intervention converts to diagnostic or therapeutic at the same session.

Billing implicationWhen screening converts to diagnostic/therapeutic, report diagnostic code secondary and screening code primary if supported by records.

Modifier PT

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

UseReport modifier PT when a colorectal cancer screening test converts to a diagnostic or therapeutic procedure during the same session.

Billing noteReport screening ICD as primary and diagnostic/abnormal finding ICD as secondary when conversion occurs; include PT when appropriate.

Modifier 33

DefinitionModifier 33: Preventive services.

UseReport modifier 33 for preventive services when appropriate.

Billing noteHealth care providers should report modifiers PT and 33 when appropriate on claims for screening colonoscopies.

Screening

DefinitionScreening: Preventive service provided to an individual without apparent signs or symptoms to identify or exclude an undiagnosed condition.

PurposeIdentify early signs of cancer in the colon or rectum in asymptomatic individuals.

Conversion possibilityA screening colonoscopy may convert to diagnostic/therapeutic if polyps are removed or abnormalities found during the same session.