Sunday, March 20, 2016

UHC coding guidelines for colonoscopy screening

Colonoscopy Screenings and Related Subsequent Diagnostic Procedures

In all UnitedHealthcare Medicare Advantage plans, a colonoscopy that begins as an in-network screening service is subject to the $0 screening cost-share regardless of whether a polyp is found and/or removed during the procedure.


• Endoscopy codes G0104, G0121 or G0105 are used for screening colonoscopies. These continue to assess a $0 in-network cost-share per the Medicare preventive services coverage guidelines.

• CPT Code 45330 (and family codes) and CPT Code 45378 (and family codes) billed with modifier PT are used if a screening turns into a diagnostic procedure. These codes, when billed with the PT modifier, will assess the $0 in-network cost-share. If the colonoscopy service is billed without the PT modifier, the claim will be processed as a surgery and the applicable cost-share will apply.

• Providers may not bill both the screening and the diagnostic services when a screening colonoscopy turns into a diagnostic procedure. Only the diagnostic code with the PT modifier may be billed in these circumstances.

• If the screening service and subsequent diagnostic procedure is performed at an out-of-network facility, applicable cost-shares will be assessed.

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