As the statutes regarding coverage of preventive services such as colorectal cancer screening change over time, our practices regarding coding and billing must be reviewed to accommodate the changes.
After the Affordable Care Act was implemented in 2010, CPT® and HCPCS billing codes were introduced to support these changes in the law. Following are some of the billing codes that are often used in conjunction with colorectal cancer screening.
Billing Modifier 33 – Commercial, Medicaid, and Medicaid Expansion
For commercial, Medicaid and Medicaid Expansion patients, billing modifier 33 should be used with a follow-on colonoscopy – that is, a colonoscopy performed as a second step of screening after a positive non-invasive screening test, such as FIT, FOBT, or Cologuard®. This modifier should be added to all related codes including the related office visits, pathology, and anesthesia. When used properly with a non-grandfathered plan, this code will eliminate coinsurance costs to the patient for the colonoscopy and all related services.
Billing Modifier KX – Medicare and Medicare Advantage
Medicare’s HCPCS billing modifier KX is similar to modifier 33 and should be used with HCPCS codes G0105 or G0121 following a positive non-invasive test to eliminate coinsurance costs to the patient.
Billing Modifier PT – Medicare and Medicare Advantage
Coinsurance will still apply with Medicare when polyps are removed during a follow-on colonoscopy, but the cost to the patient can be reduced by 80% when using the billing modifier PT with those procedure codes. This benefit is implemented in a phased approach that will eliminate coinsurance entirely by the year 2030.
Billing Modifier 52 – Commercial, Medicaid, Medicaid Expansion, and Medicare
What happens if a patient or provider chooses colonoscopy for routine colorectal cancer screening, but the colonoscopy is incomplete due to poor colonoscopy prep? This is a very common scenario but should not prevent the patient from completing colorectal cancer screening. Billing modifier 52 identifies a colonoscopy that was performed but not completely due to poor prep by the patient. An explanation must be provided with this modifier. This modifier should reduce or eliminate coinsurance, however, each plan may differ in coverage for incomplete screenings.
Billing Modifier 53 – Commercial, Medicaid, Medicaid Expansion, and Medicare
This modifier is like modifier 52 but instead identifies a procedure that was discontinued due to extenuating clinical circumstances or those that may threaten the well-being of the patient. An explanation must be provided with this modifier. This modifier may reduce the coinsurance, however, each plan may differ in coverage for incomplete screenings.
This publication is supported by the Centers for Disease Control and Prevention (CDC) under cooperative agreement NU58DP006762 awarded to Quality Health Associates of North Dakota. It contents are those of the author(s) and do not necessarily represent the official views of CDC.