The Texas Medical Association’s payment specialists continuously review health care payment plans’ newsletters and updates for items important to Texas physicians. Texas Medicine Today periodically publishes key excerpts from those newsletters that you might have missed.
If you have questions about billing and coding or payer policies, contact the specialists at paymentadvocacy[at]texmed[dot]org for help, or call the TMA Knowledge Center at (800) 880-7955. TMA members can use the TMA's Reimbursement Review and Resolution Service to help resolve insurance-related problems. Visit www.texmed.org/GetPaid for more resources and information.
Which plans require referrals?
Some BCBSTX HMO plans require primary care provider selection and referrals, and some don’t. BCBSTX has created a chart, with some added reminders, you might want to print out to help remember which is which.
Tips for coding for colonoscopies
When the initial reason for a colonoscopy is to screen for colorectal cancer, bill that procedure using modifier 33 (preventive service) for BCBSTX commercial health plans because it is a preventive service under the Affordable Care Act.
- If the purpose of the procedure is to screen for colorectal cancer and the service becomes diagnostic during the procedure, you may use modifier 33.
- Do not use modifier 33 for nonscreening colonoscopies, such as those done to evaluate or follow up on signs, symptoms, or preexisting conditions, or for other nonpreventive procedures.
- A colonoscopy procedure claim will process at the no-cost sharing benefit level as long as modifier 33 is present.
- Colonoscopies not billed with one of the preventive modifiers will not be processed as a preventive screening.
Note that for BCBSTX HealthSelect of Texas, Consumer Directed HealthSelect of Texas, HealthSelect, and Consumer Directed HealthSelect Out-of-State, the prior authorization requirement is waived for preventive colonoscopies performed by in-network physicians when the intent of the procedure is preventive and the claim is billed with modifier 33, regardless of the findings. However, you should always refer to the current BCBSTX preauthorization/prior authorization requirements lists to find out if authorization is required for colonoscopies. See the BCBSTX website for FAQs about preventive colonoscopies.
Last Updated On
October 14, 2020