2023 Gastroenterology Reimbursement and Coding Update (On-Demand) | November 2022-Screening vs Diagnostic Colonoscopy

Pdf Summary

In this presentation, the topic of screening versus diagnostic colonoscopy is discussed. The objectives of the presentation include an overview of the Affordable Care Act (ACA) and its impact on colon cancer screening, an explanation of Medicare screening colonoscopy loopholes, the definitions of average risk screening colonoscopy and diagnostic colonoscopy, and the differences between screening and diagnostic procedures for inflammatory bowel disease (IBD) patients.<br /><br />The presenter first provides an update on the ACA policy, stating that the US Preventive Services Task Force now recommends starting colorectal cancer screening at age 45. Medicare is set to begin coverage at age 45 starting in 2023. The presenter also discusses the follow-up colonoscopy after a positive stool-based screening test, stating that it is required to be covered without cost sharing.<br /><br />The presentation goes on to discuss the Medicare screening colonoscopy loophole, which previously led to additional costs for beneficiaries if polyps were discovered during the screening. However, a recent law aims to eliminate this loophole.<br /><br />The presenter then explains the differences between diagnostic and screening colonoscopies, stating that diagnostic colonoscopies are done when a patient has symptoms or abnormalities prompting evaluation of the gastrointestinal tract. Screening colonoscopies, on the other hand, are done in asymptomatic individuals. The presenter emphasizes the importance of proper coding and understanding payer policies to ensure correct billing.<br /><br />The presentation also discusses surveillance colonoscopies, which are done in patients with a personal history of colorectal cancer, adenomatous polyps, or inflammatory bowel disease. While Medicare covers surveillance as a screening benefit, many commercial insurance carriers do not.<br /><br />The use of screening modifiers, such as PT and 33, is also explained. The presenter highlights the importance of documenting medical necessity for biopsies and clarifies ICD-10 coding instructions for screening and diagnostic colonoscopies.<br /><br />Lastly, the presenter addresses the visit prior to a screening colonoscopy, stating that Medicare does not cover this visit, while some commercial payers do. The presentation concludes with practice pearls, including the need for clear physician documentation, verification of preauthorization and eligibility, and patient education on the differences between screening and diagnostic procedures.

Asset Subtitle

Kathleen A. Mueller, RN, CPC, QMC, QGMC, CCS-P, ICD-10 Proficient

Keywords

screening versus diagnostic colonoscopy

Affordable Care Act

colon cancer screening

Medicare screening colonoscopy loopholes

average risk screening colonoscopy

diagnostic colonoscopy

inflammatory bowel disease

ACA policy

follow-up colonoscopy

stool-based screening test