Preventive Coding Updates for Colorectal Cancer Screening        

To support a broader statewide initiative, One Utah Health Collaborative, to strengthen colorectal cancer screening access and reduce avoidable claim denials, Health Choice Utah has aligned preventive screening billing and diagnosis requirements for members ages 45–75. These updates are intended to improve coding consistency and support accurate reimbursement when services are performed as routine screening.        

KEY PREVENTIVE SCREENING BILLING REQUIREMENTS (AGES 45–75)        

For preventive processing, bill the appropriate CPT/HCPCS and include either:                                   

• A screening diagnosis code Z12.10, Z12.11, or Z12.12, or
• Modifier 33 (Preventive services)

STOOL-BASED TESTS        

• High-sensitivity guaiac FOBT (HSgFOBT) – CPT 82270 | Preventive benefit: 1 per year
• Fecal Immunochemical Test (FIT) – CPT 82274 | Preventive benefit: 1 per year
• Stool DNA test with FIT (sDNA-FIT) – Cologuard – CPT 81528 | Preventive benefit: 1 per 3 years

DIRECT VISUALIZATION TESTS        

Preventive benefit: 1 per 5 years

• CT Colonography: 74261–74263
• Flexible Sigmoidoscopy: 45330–45345, G0104
• Colonoscopy: 45378–45385, G0105, G0121

IMPORTANT REMINDER        

Services billed more frequently than the preventive benefit allows, outside the 45–75 age range, or performed for symptoms/follow-up of abnormal findings may process under the medical benefit rather than preventive coverage.

For questions or claim trend feedback, please contact our Customer Service team at 877-358-8797.