Updated Preventive Care Guidance regarding screening colonoscopies

On January 10, 2022, updated Preventive Care Guidance was released by the Departments of Labor, Health and Human Services (HHS), and the Treasury. This new guidance (referenced on page 11) applies to most of Empire BlueCross BlueShield’s ACA-complaint non-grandfathered health plans when services are provided in-network. This new guidance indicates:

 

On May 18, 2021, the USPSTF updated its recommendation for colorectal cancer screening. The USPSTF continues to recommend with an “A” rating screening for colorectal 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, followup 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 colcorectal 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.

 

807-0322-PN-NY