2016-06-29 11:48:44 UTC

New Colonoscopy Consultation Code May be Required

June 29, 2016

GIs may be able to report new code for non-Medicare patients.

Beginning July 1, Healthcare Common Procedure Coding System (HCPCS) code S0285 (colonoscopy consultation performed prior to a screening colonoscopy procedure) will be available to report a pre-screening colonoscopy consultation.  

In 2015, the Departments of Treasury, Labor and HHS (under question 7) stated that the plan or issuer may not impose cost sharing with respect to a required consultation prior to the screening procedure if the attending provider determines that the pre-procedure consultation would be medically appropriate for the individual, because the pre-procedure consultation is an integral part of the screening colonoscopy. This means that the patient does not have a co-pay for the visit, and that the payor is responsible for 100 percent of the payment for this service, as long as the patient is seeing an in-network provider for the screening colonoscopy, even if the patient has not met their deductible in the calendar year. The practice is not taking a financial hit for the visit; but, the practice needs to watch their payments from the payor to make sure they are getting 100 percent of the contracted amount for this service. Note that the waiver of patient financial responsibility does not apply to preventive services covered under the ACA if the patient goes to an out-of-network provider.

For non-Medicare patients who receive a pre-screening colonoscopy consultation, check with the payor to see if the physician reports S0285, rather than an evaluation and management (E/M) code. Each payor will determine reimbursement for the service. The practice needs to contact the provider relations or similar department at the health plan to find out the amount of the payment. It is up to the practice to negotiate whether this would be a level 2, 3 or 4 E/M visit, and whether the payment would be at the level of an established or new patient. Medicare does not value “S” codes.

If the patient has a number of complex medical problems that requires an E/M visit, then it might be appropriate for the practice to bill the E/M visit as they are currently doing. In that instance, though, you would not bill S0285 and the patient would be subject to the usual co-pay/deductible for that visit. We suggest that you clarify which code to bill with the health plan.

Note that S0285 is not an eligible service for Medicare beneficiaries. Medicare does not cover a pre-screening colonoscopy E/M visit prior to the procedure. Unfortunately, nothing has changed on this topic. AGA will continue to bring this issue to the attention of Congress and is committed to working to make sure that Medicare beneficiaries are eligible for the same preventive services coverage as other patients.

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