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:
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Code
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Description
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V12.72
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Personal History of
Colonic Polyps
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V16.0
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Family History of Malignant
Neoplasms of Gastrointestinal Tract
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V70.0
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Routine General Medical
Examination at a HealthCare Facility
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V70.9
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Unspecified General Medical
Examination
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V72.85
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Other Specified Examination
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V72.9
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Unspecified Examination
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V76.49
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Special Screening for
Malignant Neoplasms, Other Sites
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V76.50
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Special Screening for
Malignant Neoplasms, Unspecified Intestine
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V76.51
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Special Screening for
Malignant Neoplasms, Colon
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V76.52
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Special Screening for Malignant
Neoplasms, Small Intestine
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V76.89
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Special Screening for
Malignant Neoplasm
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V76.9
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Screening for Unspecified
Malignant Neoplasms
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