The difference between a screening and diagnostic colonoscopy has been much debated for a long time. But its importance will increase with the new health reform law. According to the law private insurers need to provide first dollar coverage within six months for colorectal screenings.
A screening colonoscopy is also called preventive colonoscopy and is done when a patient has no symptoms or any personal history of colon cancer or colon polyps. Generally the codes that are used to report it and get pay are the HCPCS code G0121. This was earlier only used by Medicare but now is also used by commercial payers. Another code used is CPT 45378 along with the diagnosis code V76.51.
Diagnostic colonoscopy is done if the patient has blood in stool, bleeding from rectum, iron deficiency anemia, change in bowel habits or abdominal pain. Additionally, if one has personal or family history of colon cancer or colon polyps, one needs to undergo diagnostic colonoscopy.
Coding becomes complicated if a polyp or lesion is found and removed by snare during the screening colonoscopy. This condition is reported with CPT code 45385 but it is tricky to select a diagnosis code.
Screening colonoscopy is fully covered by Medicare and there is no need to pay deductible and co-insurance. But for diagnostic colonoscopy, although the deductible is waived by Medicare, one needs to pay 20% co-insurance.
If one has appeared for a screening colonoscopy and has to go in for diagnostic colonoscopy, then payment needs to be done for diagnostic colonoscopy. Even if there are no symptoms found and a polyp is found, it will be termed as diagnostic colonoscopy procedure.
Screening colonoscopy is referred as a preventive service and is covered by insurance policies without a co-payment, co-insurance or deductible being met.
One needs to follow some basic guidelines for screening colonoscopy. They are as follows:
- It is essential to verify the benefits of the patient and get preauthorization.
- It is important to review payments with patient before the procedure to learn about the coverage and making them understand the meaning of screening. Informing the patient that a surgical colonoscopy is a good possibility is essential as nearly 35 percent of screening colonoscopies end up as surgical colonoscopies.
- It is advised to use both diagnosis codes. Some payers pay for a screening although a polyp is found. Si it is important to use both diagnosis codes for reporting in the claim.
- During the colonoscopy if a lesion is detected, the indication of screening and the finding must be reported and billed.
- One can reject bills if codes are not in order. In order to rectify this, one can review the claim and submit it as the insurer wants accordingly.
Symptoms should not be cited for screening because if it is a procedure of screening colonoscopy, its indication cannot be a symptom. One needs to caution the gastroenterologist and amend the notes.