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.
- No age limits.
- Follows standard insurance benefits.
- 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.