Screening Versus Diagnostic Colonoscopy: What You, Your Patients and Referring Physicians Should Know

January 04, 2011

Effective Jan. 1, 2011, Medicare will waive the co-insurance and deductible for patients scheduled for a screening colonoscopy. If the screening procedure results in a biopsy or polypectomy, Medicare will still waive the deductible if the procedure was initiated as a screening, but the patient is still responsible for the co-insurance. Most private payors also have a screening benefit that will waive the co-pay and/or deductible for patients receiving a screening colonoscopy.

The problem that many practices are facing, which will be compounded by the new benefits, is defining what constitutes a screening. Patients are presenting with symptoms and scheduled for a colonoscopy, and when they receive their insurance statement assigning a co-pay or applying the fee to their deductible, are complaining to the practice that the service should have been billed as a screening. In some cases, the insurance company is telling the patient that the claims were billed incorrectly, putting the practice in a very difficult position.

To prevent this from occurring, the practice should take the initiative and educate the patient as well as the referring physicians regarding the definition of a screening versus a diagnostic colonoscopy. The most effective method to manage this situation is to provide a form to your referring physicians similar to the following:

The patient with no GI symptoms is referred for a screening colonoscopy for the following reasons:

  • Patient age 55 with no high risk factors.
  • Patient has personal history of colon cancer or colon polyps.
  • Patient has family history (first degree relative) of colon cancer or colon polyps.

The patient is referred for a diagnostic colonoscopy because of the following symptoms:

  • Blood in stool/hemopositive stool.
  • Bleeding from rectum.
  • Iron deficiency anemia of unknown cause, confirmed by laboratory findings.
  • Change in bowel habits.
  • Persistent abdominal pain.
  • Other, please specify.

If the referral is by phone, the patient should be contacted before scheduling the procedure to determine whether they are experiencing any symptoms. If the patient acknowledges symptoms, he/she should be told that the procedure is diagnostic and will not fall under his/her screening benefits.

Though your motives may be to help your patient, once a diagnosis has been confirmed, billing the procedure as a screening would constitute a false claim punishable by a fine and/or exclusion from the federal programs, or a violation of your contract with the private payor.

The following are a few commonly asked questions about screening versus diagnostic colonoscopy:

  • What if the patient or the referring physician denies any symptoms, but when the patient comes into the office, he/she acknowledges having some problem in the past?

    The answer to this dilemma is not clear cut. It is the physician who will have to make a clinical decision as to whether the symptoms rise to the level of justifying a diagnostic procedure or whether they are insignificant. If considered insignificant, the procedure remains a screening.
  • How do you identify a procedure that was initiated as a screening but resulted in a biopsy or polypectomy?

    For all payors, the primary diagnosis/International Classification of Diseases (ICD)-9 code in box 22 of the CMS 1500 claim form should reflect the reason for the procedure, which is the V76.51 for average-risk screening or one of the other V codes that reflect why the patient is considered high risk for colon cancer. The secondary diagnosis would be the polyp or other abnormal finding requiring a polypectomy or biopsy. (Diverticulosis or internal hemorrhoids are considered incidental findings and should not be added as a billing diagnosis.) The number two should be entered in box 24E linking the polyp or other abnormal finding with the biopsy or polypectomy. For Medicare, add the PT modifier to the procedure code.
  • Is a surveillance colonoscopy (patient has no current symptoms but a polyp or cancer was identified during a previous procedure) considered a screening?

    Yes. A surveillance colonoscopy is a high-risk screening.

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