News
Preventive Colonoscopy Bulletin
Date: 05/01/25
Ambetter from Superior HealthPlan reimburses for preventive colonoscopies in accordance with state mandates and CMS guidelines. Colonoscopies, which are initiated as a preventive screening colonoscopy, and during which a polyp/tumor or other procedure due to an abnormality is discovered, should still be considered a preventive service. To ensure appropriate reimbursement, the preventative colonoscopy CPT code should be billed with an ICD-10 diagnosis code corresponding to the pathology found rather than the special screening for malignant neoplasms of the colon.
The preventive colonoscopy diagnosis should be entered as the primary diagnosis and the diagnosis codes for any discovered pathology should be entered as the secondary diagnosis on all subsequent claim lines.
Follow the below billing tips to appropriately identify the colonoscopy service to be considered for reimbursement.
Preventive Colonoscopy Screening:
- One preventive colonoscopy every ten years when billed with preventive screening procedure and preventive diagnosis (must be billed in diagnosis 1 field); and
- Does not require modifier PT or 33 to be billed.
High Risk Colonoscopy Screening:
- One preventive colonoscopy every 24 months when billed with a high-risk procedure code and a high risk diagnosis code; and
- Does not require modifier to be billed.
Diagnostic Colonoscopy Services:
- When billed with modifiers PT or 33, will be treated as preventive.
- When a modifier is not billed, it indicates the service is diagnostic and will be subject to member cost-share, as applicable.
For more information about the U.S. Preventive Service Task Force (USPSTF), please visit the USPSTF website.
To learn more about the final recommendation for colorectal cancer screening from the USPSTF, please visit the USPSTF Colorectal Cancer Screening webpage.
For additional information on preventative care please visit Ambetter’s Your Better Health Center - Your Guide to Preventing Colorectal Cancer webpage.