Colonoscopies following a positive stool- or blood-based test are screening tests for Kentucky members

Note that the information below only applies to Anthem Blue Cross and Blue Shield local Commercial plans in Kentucky, Kentucky Medicaid, and the Kentucky Government Employees Association. Also note that is guidance may differ from Medicare.

 

Kentucky is a unique state regarding the legislative measures passed related to colorectal cancer screenings. We are providing information on how these measures affect stool- or blood-based testing and the billing of screening vs. diagnostic colonoscopies.

 

First, to be eligible for stool- or blood-based testing, individuals must be asymptomatic and of average risk. Colorectal cancer screening using these methods is a two-part screening test, as illustrated below.

 

Colorectal cancer screening of individuals who are asymptomatic and of average risk
Step 1	Result	Step 2
Appropriate testing such as: fecal immunochemical tests (FITs) multi-target stool DNA test (aka Cologuard®)	Positive	A completion screening colonoscopy. This test is not considered diagnostic.

 

A completion screening colonoscopy following a positive stool- or blood-based test is not separate, but rather an integral screening process of individuals who are, at this point, still asymptomatic and remain at normal risk.

 

This is not to be confused with a diagnostic colonoscopy appropriate for individuals with symptoms, elevated risks (Crohns’ or colitis), or prior personal histories of colon polyps or colon cancers that require colonoscopy-based examinations.

 

Eligibility. When providers contact Anthem to verify benefits for the completion screening colonoscopy of members in Kentucky benefit plans, please specify:

• The benefit plan is based in Kentucky.
• The member had a positive result from either stool- or blood-based testing and now needs a completion screening colonoscopy.
• The colonoscopy is not for diagnostic purposes.

 

Claims filing. Screening colonoscopies are included as a covered preventive care service. Since colonoscopies are rendered for both screening and diagnostic purposes, it is very important for providers to use appropriate coding guidelines when reporting colonoscopies. When inappropriate CPT and ICD-10 codes are submitted on claims, it can result in incorrect provider payment and/or incorrect member cost sharing.

 

Please contact Provider Services if you have questions.

 

Resource:

The Kentucky Colon Cancer Prevention Program – https://chfs.ky.gov/agencies/dph/dpqi/cdpb/Pages/coloncancer.aspx

 

1125-0521-PN-KY