Colorectal Cancer Screening: Proper Billing Tips

With Colorectal Cancer Awareness Month occurring in March, now is a good time to review key billing procedures to ensure accurate claim processing.

As you know, the United States Preventive Services Task Force (USPSTF) recommends colorectal cancer screening for all adults starting at age 45. Individuals with family history or other risk factors may need earlier or more frequent screening.

Billing for Patients Under 45

To ensure no cost-share is applied for individuals under 45, the claim must include screening for colon cancer (Z12.11) along with a secondary high-risk diagnosis code, such as a family history of polyps (Z80.0). Claims submitted without a high-risk diagnosis code will be denied.

Anesthesia and Pathology Claims for Colonoscopies

For anesthesia or pathology services related to a colonoscopy, the colonoscopy claim must be processed and in our system before submitting claims for these associated services. This sequence is critical to ensure no cost-share is applied.

Claims with Highmark as Host Plan (for Other Insurers)

If Highmark is acting as the host plan for a colon screening claim on behalf of another health plan, and you encounter claim issues or denied services, please direct your inquiries to the patient's primary "home" health plan.

Important Reminder: No Cost-Share for Preventive Colonoscopies 

Highmark members aged 45 and older are eligible for a preventive colonoscopy every 10 years with no cost-share, or more frequently as recommended by the physician based on findings indicating high-risk, such as polyps. This is a covered benefit under their preventive health plan.