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

04 - Screening vs Diagnostic Colonoscopy_Mueller

Pdf Summary

The speaker discusses the differences between screening and diagnostic colonoscopies. Screening colonoscopies are performed on individuals without symptoms or a personal history of GI diseases or malignancies. The age of eligibility for screening was revised to start at age 45 by the American Cancer Society, but many payers still start at age 50. Medicare covers screening colonoscopies at 100% since 2011. The frequency of screening colonoscopies varies depending on the patient's coverage/plan.<br /><br />If a polyp or lesion is found during the colonoscopy, it is no longer considered a screening but a surgical endoscopy. The Affordable Care Act allows for no patient financial responsibility when average-risk screening is the indication and a lesion is found. However, Medicare patients are responsible for the 20% not covered by Medicare. The phase-out of cost-sharing for screening colonoscopies for Medicare patients begins in 2023. Commercial payers may consider repeat screenings as surveillance and not cover them under preventive benefits.<br /><br />For billing purposes, it is recommended to indicate screening as the primary diagnosis and the finding as the secondary diagnosis. This allows most payers to continue to pay preventive benefits. Modifiers PT and 33 can be used to trigger preventive benefits for Medicare and commercial payers, respectively.<br /><br />The speaker also discusses high-risk screening, diagnostic/therapeutic colonoscopies, and surveillance colonoscopies. The appropriate diagnosis codes and modifiers to use for each type of colonoscopy are provided.<br /><br />The guidelines and recommendations of the American Cancer Society and the US Preventive Services Task Force are discussed, as well as the requirements for pre-procedure consultations and visits prior to screening colonoscopies.<br /><br />The speaker concludes by emphasizing the importance of clear documentation, verifying preauthorization and eligibility, understanding payer policies, and educating patients about the differences between screening, high-risk screening/surveillance, and diagnostic colonoscopies.

Keywords

screening colonoscopies

diagnostic colonoscopies

age of eligibility

Medicare coverage

patient financial responsibility

billing purposes

high-risk screening

therapeutic colonoscopies

surveillance colonoscopies

payer policies