Important reminder: Preventive care guidance for colonoscopy screening

On January 10, 2022, updated Preventive Care Guidance was released by the U.S. Departments of Labor, Health and Human Services (HHS), and the Treasury. This new guidance applies to most Affordable Care Act-compliant non-grandfathered health plans like Anthem Blue Cross and Blue Shield (Anthem) when services are provided in network.

This new guidance indicates:

On May 18, 2021, the United States Preventive Services Task Force (USPSTF) updated its recommendation for ectal cancer screening. The USPSTF continues to recommend with an “A” rating screening for ectal cancer in all adults aged 50 to 75 years and extended its recommendation with a “B” rating to adults aged 45 to 49 years. In its “Practice Considerations” section detailing screening strategies, the Final Recommendation Statement provides: “When stool-based tests reveal abnormal results, follow up with colonoscopy is needed for further evaluation…. Positive results on stool-based screening tests require follow-up with colonoscopy for the screening benefits to be achieved.” Additionally, the Final Recommendation Statement provides with respect to direct visualization tests: “Abnormal findings identified by flexible sigmoidoscopy or CT colonography screening require follow-up colonoscopy for screening benefits to be achieved.”

For a follow-up colonoscopy after a positive non-invasive stool-based screening test or direct visualization screening test for ectal cancer, in-network providers should code the claim as a screening colonoscopy rather than as a diagnostic colonoscopy.

Providers can contact the Provider Service number on the back of the member ID card to determine if a member’s plan includes this benefit.