Colonoscopy Coverage Update

Effective June 1, 2022, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will cover screening colonoscopies at 100% of the allowed amount after positive stool-based (FIT, DnA-FIT, gFOBT) or direct visualization (sigmoidoscopy or CT colonography) tests for eligible members if these tests were ordered as a screening exam. (i.e., for a patient who is asymptomatic and due for a screening based on U.S. Preventive Services Task Force guidelines).

If a colonoscopy is performed following a positive stool-based or direct visualization screening test, the exam should be billed with a screening diagnosis as the primary diagnosis on the claim line of the test performed in box 24E and not just in the header diagnoses, box 21. Failure to list screening as the primary diagnosis code will affect how the claim is adjudicated and the member’s out of pocket cost. Any abnormal findings from a screening test should be listed as a secondary diagnosis code.

If you have any questions, please review the Health Care Reform Preventive Services Coding Guide (PDF) or call the Provider Blue Line^℠ at 800-214-4844.