Covered Diagnosis - Colon Cancer Screening preventive service

PREVENTIVE SERVICES PAYMENT POLICIES

Colon Cancer Screening

Requirements

HMO/POS
 Referrals are required from Primary Care Physician to a Contracting Provider.
 Services subject to benefit limitations.
PPO/PBA
 Services are subject to benefit limitations.

Limitations and Exclusions
Limitations:
Colorectal cancer screening, which includes:
 Fecal occult blood (age 50 or older) annually if not part of the annual well-woman exam; and
 Barium enema or Sigmoidoscopy (age 50 or older) once every five (5) years; or
 Colonoscopy (age 50 or older) once every ten(10) years.

Provider Billing Guidelines and Documentation
In order for Claims to be processed to the Preventive Service Benefit, the provider must submit with the following diagnosis and service codes:

Code

Description

V12.72

Personal History of Colonic  Polyps

V16.0

Family History of Malignant Neoplasms of Gastrointestinal Tract

V70.0

Routine General Medical Examination at a HealthCare Facility

V70.9

Unspecified General Medical Examination

V72.85

Other Specified Examination

V72.9

Unspecified Examination

V76.49

Special Screening for Malignant Neoplasms, Other Sites

V76.50

Special Screening for Malignant Neoplasms, Unspecified Intestine

V76.51

Special Screening for Malignant Neoplasms, Colon

V76.52

Special Screening for Malignant Neoplasms, Small Intestine

V76.89

Special Screening for Malignant Neoplasm

V76.9

Screening for Unspecified Malignant Neoplasms