2022 Gastroenterology Reimbursement and Coding Update: Concrete Solutions to Strengthen Your Foundation in GI Coding and Billing | November 2021-04 - Screening vs Diagnostic Colonoscopy

04 - Screening vs Diagnostic Colonoscopy_Mueller

Pdf Summary

The document discusses the difference between screening and diagnostic colonoscopies. It defines average risk screening as the absence of symptoms, abnormalities, and personal history of GI disease or malignancy. The age for screening eligibility was revised by the American Cancer Society (ACS) from 50 to 45, but most payers still start eligibility at 50. Medicare covers screening at 100% with no patient financial responsibility since 2011, while commercial payers' coverage frequency varies. When a polyp/lesion is found during a colonoscopy, it is no longer considered screening but a surgical endoscopy. The ACA allows no out-of-pocket patient responsibility for average risk screening with a found lesion. Medicare patients are responsible for the 20% that Medicare does not pay, but the screening colonoscopy loophole will close in 2030. The document also describes surveillance colonoscopies for high-risk patients and the difference in coverage from Medicare and commercial payers. Various modifiers associated with screening and their usage are explained, including modifier 33 for commercial payers and modifier PT for Medicare. The document provides examples of diagnosis codes and proper coding for screening versus diagnostic colonoscopies. Other topics covered include pre-procedure consultations, billing the visit prior to screening, contradictory indications, and practice pearls. Overall, the document provides a comprehensive overview of the issues and considerations surrounding screening versus diagnostic colonoscopies.

Keywords

screening colonoscopy

diagnostic colonoscopy

average risk screening

GI disease

malignancy

screening eligibility

American Cancer Society

Medicare coverage

commercial payer coverage

surgical endoscopy