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Medical Policy Revision: Colorectal Cancer Screening

Effective February 4, 2019, we will change the way claims for certain colorectal cancer screen services should be submitted to us and how we will process those claims based on revisions to our Colorectal Cancer Screening medical policy content.

Access our Medical Policy Manual to review this medical policy content.¹


Include Modifier QW on Claim Submissions
When submitting claims for colorectal cancer screen services rendered on February 4, 2019 and after, please ensure that Modifier QW is appropriately appended to:

  • CPT® code 82274 for patients enrolled in Horizon Blue Cross Blue Shield of New Jersey Commercial plans, Administrative Services Only (ASO) plans and Medicare Advantage (MA) plans
  • HCPCS code G0328 for patients enrolled in Horizon BCBSNJ Commercial and ASO plans.

Impact to Claim Processing and Reimbursement
Based on the revisions to our Colorectal Cancer Screening medical policy content, claims for services provided February 4, 2019 and after will be processed as noted below.

  • CPT code 82274 and/or HCPCS code G0328 will not be considered for reimbursement if NOT appropriately appended with Modifier QW as noted above.
  • Medical record information may be requested to help us determine the medical appropriateness of the services represented by CPT code 82274 included on claims for Horizon BCBSNJ MA patients.

    Following our review of medical record information, the services represented by these codes may be denied as not medically necessary.

Unless Horizon BCBSNJ gives written notice that all or part of the above changes have been cancelled or postponed, the changes will be applied to claims on and after February 4, 2019.

¹ The content of Horizon BCBSNJ medical policies that apply to services provided to Horizon BCBSNJ MA members include reference to pertinent National Coverage Determinations (NCDs) and/or Local Coverage Determinations (LCDs). Horizon BCBSNJ follows Centers for Medicare & Medicaid Services (CMS) guidelines, NCDs and LCDs in our processing of claims for services provided to Horizon BCBSNJ MA members. For those services where no LCD or NCD exists, claims for services provided to MA members will be processed based on our policy guidelines.

CPT® is a registered mark of the American Medical Association.

Published on: November 5, 2018, 12:03 p.m. ET
Last updated on: November 11, 2018, 23:39 p.m. ET