This was common on non-Medicare claims before the ACA. For a screening colonoscopy under the ACA, the provider now bills modifier 33 with the procedure code to prevent cost sharing.My DH, 60 yrs old, signed up for a colonoscopy. Since it's a preventative there's no cost to us, or so we thought. I started reading articles where people had the preventative colonoscopy. They found benign polyps and were charged for diagnostic colonoscopy, big difference!
If the provider forgets to bill the modifier and cost sharing is applied, the provider submits a 'corrected claim' with the modifier and the cost share is removed.
If the colonscopy is being performed due to symptoms (pain, bleeding), it is diagnostic and cost sharing does apply.
A screening test is a test provided to a patient in the absence of signs or symptoms based on the patient’s age, gender, medical history and family history according to medical guidelines. Whether a polyp or cancer is ultimately found does not change the screening intent of that procedure.
Screening Colonoscopy for Non-Medicare Patients that becomes Diagnostic or Therapeutic
When a screening colonoscopy converts to a diagnostic or therapeutic procedure for a non-Medicare patient, the surgeon must document that the intent of the procedure was screening in order for the patient’s insurance to process the claim without out-of-pocket expense in accordance with the ACA.
CPT developed the 33 modifier for preventive services...
For example, if a surgeon performing a screening colonoscopy finds and removes a polyp with a snare, use CPT code 45385 and append modifier 33 to the CPT code.
Reference: Colonoscopy Coding Guidelines | Screening Colonoscopy | ICD 10 & Modifier 33