Tuesday, June 22, 2010

routine colonoscopy screenings billing rule

 TRICARE Policy Update - Routine Screening Colonoscopy

Recently, TRICARE changed their policy for routine colonoscopy screenings.


Unlike a diagnostic colonoscopy, a routine colonoscopy performed for colorectal cancer screening in the absence of cancer or other presenting signs is a limited benefit under TRICARE. For services received on or after March 15, 2006, the TRICARE Policy Manual (found online at www.tricare.osd.mil) now defines coverage as follows:

New benefit: One routine colonoscopy screening is covered every 10 years for individuals beginning at age 50. For individuals with hereditary non-polyposis colorectal cancer syndrome: A colonoscopy should be performed (i) every two years beginning at age 25, or (ii) five years younger than the earliest age of diagnosis of colorectal cancer, whichever is earlier. Annual screenings should occur after age 40. For individuals with familial risk of sporadic colorectal cancer, i.e., first degree relatives with sporadic colorectal cancer or adenomas before the age of 60 or multiple first degree relatives with colorectal cancer or adenomas: A colonoscopy should be performed every three to five years beginning 10 years earlier than the youngest affected relative. Otherwise, routine colonoscopy screening is not a covered benefit for TRICARE beneficiaries

Note: Medicare-covered TRICARE beneficiaries – for most TRICARE beneficiaries who are age 65 and over, routine colonoscopy screening would be covered separately by Medicare.

Similar Routine Exams For Colorectal Cancer Screening That Are Also Covered

The routine screening exams that TRICARE covers include:

Digital rectal exams (annually for high-risk men ages 40-49; and all men over age 50) Fecal occult blood testing (annually after age 50) Proctosigmoidoscopy or sigmoidoscopy (every three to five years after age 50)  Referral May Be Required
If it is determined that a colonoscopy is needed, providers may need to submit a referral request to Health Net to refer the patient to a gastroenterologist.

The referral request is for a consultation with the gastroenterologist, not for the colonoscopy. The colonoscopy itself does not require a prior authorization, but it is important to note that not all screening colonoscopies are covered under the TRICARE benefit guidelines. In particular, preventive or routine colonoscopy screenings that are done in the absence of symptoms or known disease are covered only in limited circumstances as noted above.

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