Tuesday, July 28, 2015

What is Diagnostic Colonoscopy and High risk screening/surveillance


High risk screening/surveillance: Patients who have a personal history of adenomatous polyps, colorectal cancer or inflammatory bowel disease, or a family history of adenomatous polyps, colorectal cancer, familial adenomatous polyposis or hereditary nonpolyposis colorectal cancer.

  • Medicare defines family history as including only first degree relatives (siblings, parents or children)
  • Commercial payors may define family history to also include two or more second degree relatives. If there are questions, check the patient’s SPD and/or the plan’s coverage policies.
  • Hyperplastic polyps do not meet the definition of adenomatous polyps; patients who only have hyperplastic polyps are considered to be average risk if there are no other high-risk factors, as described above.
  • For high-risk patients, repeat screening is covered by Medicare after a minimum of two years and covered at 100 percent.
  • Billing for screening/surveillance colonoscopy in a high risk patient:

                                    • Medicare: G0105
                                    • Commercial, exchange, Medicaid, Tricare: 45378

  • Many payors have screening policies, which indicate that once the patient has a condition that requires surveillance at intervals of less than 10 years, the patient is no longer eligible for preventive benefits. 

                   • This causes much misunderstanding by patients.
                   • Eligibility needs to be verified on all patients prior to scheduling.
                   • After eligibility is verified, a thorough explanation of the patient’s benefits and financial responsibility should be given to the patient in order for the patient to make an informed decision.

What is a diagnostic colonoscopy?
A diagnostic colonoscopy is a procedure performed for the evaluation of a patient who presents with symptoms and/or abnormalities prompting evaluation of the lower GI tract.

  1. No age limits.
  2. Follows standard insurance benefits.
  3. Payors may use external criteria for determining coverage (medical necessity) such as MCG, InterQual or the 2012 ASGE Appropriate Use of Gastrointestinal Endoscopy Guideline.


CAUTION: If a patient undergoes a CRC screening test, such as a fecal occult blood test (FOBT), fecal immunochemical test (FIT) or CologuardTM, by another health-care professional and an abnormality (e.g. positive test) is found that prompts referral for a colonoscopy, the colonoscopy is no longer a screening procedure and for Medicare is no longer a preventive service.


  • For Medicare, this means that the patient is now responsible for the co-pay and deductible for the diagnostic colonoscopy.
  • For commercial payors, check the SPD and/or payor policy to see if a colonoscopy performed in an asymptomatic patient with a positive FIT or FOBT is still a preventive service (with waiver of financial responsibility) or not.


QUESTION: Our doctors see a patient in the office prior to a screening colonoscopy. The doctors take a complete history, do an ROS and a thorough exam. If the only diagnosis is “screening for colon cancer,” can we still bill an office visit? 

ANSWER: For Medicare, unless the patient has symptoms or a chronic condition/disease that has to be managed by the GI provider, an E/M visit prior to the colonoscopy is not covered and will be denied with no patient responsibility. If you inform the patient ahead of time that this visit is non-covered and they wish to pay for it out of pocket, that is the patient’s option. An advance beneficiary notice (ABN) is not required, but it is sensible to obtain a waiver of some type. If the patient insists that the visit is billed to Medicare, use an unlisted E/M code with GY modifier, which tells carrier it is a noncovered service and the denial shifts to patient responsibility.

For private payors, it will depend whether preventive visits are covered. This is not a consultation since there is no request for a consult, but just a transfer of care since the request is for preventive procedure to be done. Remember that when billing new patient (99201–99205) or existing patient (99212–99215) E/M codes, there should be a chief complaint. Utilizing E/M visit codes with a screening diagnosis may not make sense to the payor since the patient undergoing screening should have no symptoms and this is considered a preventive visit, not a “sick” visit. Each payor may have individual policies; for instance, Anthem BC/BS policy is to bill this as a preventive visit 99381–99397. It is up to each practice to query the most common payors to find out policy and also to check eligibility upon patient scheduling/appointments.

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