And we're going to be talking about screening versus diagnostic colonoscopy, the confusion that keeps on giving. And I think it's going to keep on and keep on and keep on. All right, so we're going to kind of talk about some, there's quite a few components to this presentation. Under the Affordable Care Act, Medicare screening colonoscopy loophole. What is average risk screening? What are the options that we have for billing? What are the codes? What's considered high risk surveillance? What's diagnostic? Screening versus diagnostic for IBD patients. The modifiers that we use for screenings. Billing the visit before screening, which we kind of just covered in the Q&A section and the False Claims Act. All right, so the Affordable Care Act update on screening. So this was actually published back in May 18th of 2021. And that's when the first time the task force was recommending that screening started age 45. So this became a mandatory following by the commercial payers that followed the Affordable Care Act policies. And that became mandatory on May 31st of this past year, of 2022. All right, and they broke it down into grade A, grade B, and grade C. So grade A includes adults 50 to 75. Grade B is adults age 45 to 49, and grade C includes adults age 76 to 85. And you were going to have to look at individual payer policies as far as what the coverage allows. There are some exclusions for grade C from some payers. Some payers state that they won't cover after age 76. Some say they will cover based upon the patient's quality of life. Some say they will cover it for everybody up until 85. All right, so every payer has different policies. So this is what I was talking about earlier, is making sure that pre-authorization is done, eligibility is verified. Now we all know that Medicare is to begin coverage at age 45 on January 1st of 2023. Humana Medicare also published that they started covering Medicare, like I said, Humana Medicare will cover age 45, and they started it on November 12th. And they also started following the guidelines too for a positive screening stool test to be also covered as a screening colonoscopy as well. So they begin coverage already on November 12th. So that's one of the Medicare plans that we know about. And like I said, when I started talking about the updates, is expect to see more and more payers have published their policies when they begin, et cetera. All right, we talked about the ACA update on follow-up colonoscopy for positive stool. All right, and we know that they began policy May 31st, and Medicare is to begin coverage January 1st of 2023. The Medicare screening colonoscopy loophole, all right, so this has always been an issue that for Medicare, they did not follow the Affordable Care Act guidelines. They considered that if a screening colonoscopy became a diagnostic or surgical procedure, that the patient would still have a waive co-pay when we used a PT modifier on say a snare. It tells the Medicare payer to waive the patient's deductible, but the patient then became responsible for the 20% that Medicare did not pay because they considered this a surgical procedure. So the phase out of cost sharing begins in 2023, right? So this was actually passed back in 2020, but it doesn't go into effect till January 1st. So right now, the patient has a 20% responsibility if a polyp is found during a screening and it's removed. In 2023, the patient's responsibility goes down to 15%, and CMS approved amount goes up 85%. 2027, it's now 90-10, and then in 2030, finally, the patient has no out-of-pocket responsibility and CMS pays the full 100%. So if you really want to see where this bill came through, I have a link there, and you would have to go to page 2175 to find it. All right, so screening versus surveillance versus diagnostic colonoscopy. So diagnostic colonoscopy, the patient has symptoms or other abnormality-prompting evaluation of the GI tract, diarrhea, hematochesia, abdominal pain, change in bowel habits, weight loss, anemia, abnormal X-ray of the GI tract, all of this is considered diagnostic, diarrhea. I think this is the most common scenario we see, all right? And, you know, a lot of times we'll see that the indication is screening an incidental diarrhea, but biopsies of normal tissue are done to rule out microscopic colitis. That's not incidental, right? If you're doing something, if you're altering your care plan because of a symptom, that is not considered diagnostic. Now if you find something during that procedure, some erythema, nodules, et cetera, that warrant a colonoscopy, that is medically necessary, right? The patient had no symptoms or no abnormalities. So the definition of diagnostic, again, patient has symptoms and abnormalities-prompting evaluation of the lower GI tract. There is no age limits on diagnostic. It follows standard insurance benefits, and there are no frequency limitations. You do a diagnostic whenever there is an indication for this. Now, we do have payers that have certain approved diagnosis codes for this, and Medicare's had local coverage determinations for years, all right? And you'll have to see what's covered and what isn't. And this is something that needs to be printed and given to all of the providers. It needs to be given to anybody that does pre-authorization, anything that, anybody that codes, and anybody that processes payments. So that means almost everybody in your practice should have a copy of this, right? And keep in mind that these guidelines get reviewed and they get updated, all right? Sometimes the payers get rid of the LCD, all right? Sometimes they add new guidelines, they take away approved diagnosis codes. We also have commercial payers that also have policies on this as well, which, with approved diagnosis codes. They also have indications. They have contraindications, all right? So these need to be read through very closely by our providers, which means they have to document appropriately. All right, so definition of screening. This is lack of symptoms and abnormalities. The patient is eligible for screening colonoscopy by most payers after age 45, all right? So Medicare covers it 100% on screening. It's allowed every 10 years by Medicare. We're talking about average risk screening. And the frequency for commercial payers is dependent on patient's coverage and plan. The Affordable Care Act says that they will allow one average risk screening once every 10 years, all right? So a lot of our payers follow the Affordable Care Act guidelines. They follow it when it's to their benefit. So during the screening procedure, if a polyp or lesion is found, which is removed, it does change the designation from screening to a surgical colonoscopy, and it can increase the patient's financial responsibility, even though the intent was screening. So if filled with a screening as a principal diagnosis and the finding is the secondary, most payers will continue to pay preventive benefits, all right? For Medicare, we're going to add the PT modifier to the surgical clean, which waives the patient's deductible. And currently, the patient is responsible for 20%. But I just said after January 1st of 2023, it will go down to 15. For commercial payers, we would add modifier 33 to the surgical clean, which still triggers preventive benefits. Now, when we're talking about which diagnosis is code is primary, we have to know what the payer wants. Some of our Medicare payers do not want screening in the first position. If you add a PT modifier, it tells them it's preventive, so therefore they want to see the finding. And the same with our commercial payers. If we're adding the 33 modifier, some of our payers don't want screening in the first position. All right? They actually want to see the findings. So this is where a spreadsheet is created by payer based upon what your explanation of benefits, what the payers want, so that we know which goes first. It's like the chicken or the egg, which comes first, same thing, which modifier is added and which diagnosis code goes first. Remember, and this is just kind of rule for thumb, that first diagnosis code that you add to every claim is the one that determines payer coverage. So GL-121 is the code we use for colorectal cancer screening. It's on an individual not at high risk. The diagnosis code submitted is Z1211. Most of our commercial payers also use these codes as well. And if you're not sure, and this is one of the things that both Kristen and I, when we audit, you know, when we're auditing practices, you know, we look at what was billed and what was submitted, et cetera. And if the payer that you're dealing with accepts the G codes, and I go online, I check when I start to work with the practices. So if they're doing like Empire Blue Cross and Blue Shield, you know, so I look in their site and I see what codes that they accept. And Empire does accept GL-121. United Healthcare administers a lot of plans. They accept GL-121. We want to make sure that the screening benefit is triggered for that patient. You know, that's our priority. We want to make sure that we don't have to answer a phone call, all right, by the payer saying that you coded it wrong, or not necessarily the payer, but the patient. You know, if that payer allows a G code, we're going to submit it with a Z1211 so it gets processed as screening. All right. High risk is GL-105, which is colorectal cancer screening on an individual at high risk. So this is covered at a frequency of once every two years, which means at least 23 months from the last screening colonoscopy. And the only code that actually starts a time clock is a G code. There are no frequency guidelines for diagnostic colonoscopy. It's only screening. If you are actually billing a surgical code and you're adding a 33 or the PT modifier, that does not start the time clock, only the G codes. So what's considered surveillance? The patient is asymptomatic and has a personal history of colorectal cancer and nominous polyps, IBD. Many commercial insurance carriers and Medicare replacements do not cover under screening benefits. The Affordable Care Act states that they will allow one average of screening once every 10 years. All right. Anything less than that is not considered a screening or preventive benefit. If you go on all of the payer websites, they pretty well say the same thing. Medicare does cover surveillance, the same as a screening benefit, 100% for G codes and 20% copay of polyps are removed. Some carriers do cover G0105 as preventive regardless of diagnosis. So again, it is based on payer policies. So what is surveillance and why don't some carriers cover it as preventive? So surveillance is an endoscopic exam performed to identify a recurrent neoplasia in an asymptomatic individual. Previously identified precancerous lesions, adenominous polyps or adenomas are polyps that grow on the lining of the colon and which carry a high risk of cancer. Some of them are considered premalignant. The other types of polyps that can occur in the colon are hyperplastic and inflammatory polyps. Do not confuse yourself. Inflammatory polyps, and this is an ICD-10 issue. If you're trying to find a code for inflammatory polyps, it's going to take you to K51.4, which is ulcerative colitis with pseudopolyps. Unless the patient has ulcerative colitis, you do not assign that code. An inflammatory polyp is just reported as K63.5, which is just a colon polyp. The Affordable Care Act, which most commercial insurance follows, left a loophole, like I said before, which specified a screening regimen as every 10 years and surveillance as anything less. Medicare does not follow the ACA, so that's why Medicare still allows the G0105 as a high risk screening and still covers that at 100%. Remember what I was talking about with some of the payers have policy on this? UnitedHealthcare policy and personal history of adenomous polyps. This is from their frequently asked questions. If a polyp is encountered during a preventive screening colonoscopy, are future colonoscopies considered under the preventive care benefit? It says no. If a polyp is removed during a preventive screening colon, future colonoscopies would normally be considered to be diagnostic because the time intervals between future colonoscopies would be shortened. You can look on Aetna site. You can look on Humana site. You can look at Anthem site, all the same. Do patients with inflammatory bowel disease, such as Crohn's or ulcerative colitis, qualify for high risk screening? If the provider proceeds under the same guidelines as a routine screening, all you're going to do is just view the colon and only biopsy abnormal appearing tissue, then yes, it can be billed as screening. If no biopsies are taken, this would be billed as G0105. This is the issue, and this is where we often see with our providers. The intent prior to proceeding with the procedure is to randomly biopsy the colon to assess how medication is keeping disease under control. This is considered diagnostic, not screening. Random biopsies are really never taken during a screening colonoscopy, unless there's what? Unless there's an issue. Unless the patient has a medical condition that has to be monitored. Unless the patient has a symptom. So if the IBD patient questions whether or not the colon will be billed as screening, you need to check with your provider and determine what the intent is. That causes us a little problem every once in a while, but a lot of our patients think they're eligible because they're age 45 now. So you do have to make sure, this is where pre-authorization verification of eligibility is very important. So screening modifiers, I talked about PT and 33. All right, they're screening modifiers, and which one you use is carrier-specific. So we don't use the PT or 33 on G codes because it automatically says this is screening. This is a screening code. If the payer does not accept the G code, then we can add the 33 modifier. PT for screening turned into diagnostic. This is where the polyp is removed. We talked about this. It waives the deductible, although the patient's currently still responsible for the 20% copay. If you're going to add 33, like I said, on billing the 4, 5, 3, 7, 8 to carriers not recognizing the G code or on surgical CPT codes when polyps are removed. Now we have two modifiers, 52 and 53. Modifier 52 is added when the scope is past the splenic flexure but did not reach the cecum. A polyp is removed, a therapeutic procedure is done, there's a poor prep, and there's a plan to repeat at a later date. All right, 53 is for an incomplete screening. This means all you did was look and not touch. You're going to use this on a G code or 4, 5, 3, 7, 8 only. The scope passed the splenic flexure but did not reach the cecum. All right, so 52 versus 53 is based upon what you did during that procedure. 74 goes on an ASC charge when the physician bills the 53 modifier. So some issues encountered during screening. You were supposed to bill a screening. I'm sure you guys have heard this. So any providers that are listening in, you guys don't really get involved in this unless the patient actually talks to you about this. Most of the time, this is what your staff has to deal with. So does the patient meet the minimum age requirements for screening? So remember, it's currently age 45 for the majority of carriers except Medicare. Don't immediately assume the patient is incorrect. That's one of the biggest things is to go back, look at the note. The patient's carrier may allow screening diagnosis to be billed primary for patients with personal history of polyps and process as preventive. This is very common. The patient calls the payer. The payer says, well, doctor, to add a screening, it would have been covered at 100%. Hmm, yeah. And that's usually the end of it because that person at the payer wants to get the patient off the phone. So then the payer is all upset, calls you and said, well, the insurance company said if you'd added the Z1211, it would have been processed as preventive. All right, well, then our response is, but you didn't have average for screening. We billed because you had a history of polyps. All right, well, that's what the insurance company said. Well, make sure, you know, if you want to definitely get us on the phone with the insurance company, we'd be happy to do that for you. And this is most of the time where then the patient calls, sets the appointment, and now you get to talk to the claims rep because oftentimes who the patient talked to was not the claims rep. All right, and then the claims rep says, you have a history of polyps. You're not covered. That's, you're not going to have a preventive service. All right, so that kind of takes care of it, but that they say, oh, well, your policy allows for the payment as long as you're asymptomatic, right? So as long, you know, so if that policy is in writing and they send it to you, then you can. But most of the time, most of the time, we actually get backed up on this one. All right, so, you know, we all make mistakes. Sometimes we don't, we didn't look at the chart right. There could have been wrong information entered in the colon report. The patient had a family history of polyps, but personal history was entered. So there sometimes are issues. So, you know, we do want to do a double check just to make sure we build it correctly. What about the patient is asymptomatic, but that isn't why we are doing the colonoscopy? This does happen, so it's up to your physician, your provider, to identify the medical necessity for any procedure. If the patient has a symptom, but that is not why the colonoscopy is being ordered, they need to document that in the visit note. Now remember that sometimes why these get pulled has to deal with the patient's claim history, not your visit notes, not your codes, but what's been built, you know, so example, chronic patient has chronic constipation and you're managing, you're managing the chronic constipation by Miralax and diet. And your note says, does not require endoscopic exam, patient eligible for screening, and this will be scheduled. Then we know you're managing the constipation. That's not why we're doing the procedure. So the patient is still going to be eligible for a screening colonoscopy. All right, another one, intermittent abdominal pain due to known history of IBS, no endoscopic evaluation indicated patient to be scheduled for screening colonoscopy at their convenience. All right, so you are addressing the symptom. You're saying that that symptom doesn't mean the patient needs any endoscopic evaluation. They're still eligible for screening. That's how crystal clear that you should be in your notes. And then the only indication on the colonoscopy report should then be screening. Now there's some issues with this because sometimes you're not clear on this. So if you say, for instance, the patient's had rectal bleeding, most likely due to known hemorrhoidal disease, but can't rule out a higher origin, then you know what? That's still diagnostic. If you say that the patient's bleeding is due to known hemorrhoidal disease and colonoscopy, endoscopy is not indicated, screening will be done, then you also have said, I know the bleeding is due to hemorrhoids, and we're going to do the colonoscopy for screening purposes. Although I'm going to be honest, that usually is not documented well. Most of the time, rectal bleeding possibly due to known hemorrhoidal disease is not usually enough to support that it is done for screening purposes. So it is completely up to the provider to be clear. All right, I mentioned this before. Biopsies to rule out microscopic colitis for screening. Remember, screening means no symptoms, so why are biopsies done on normal mucosa? So medical necessity for biopsies based upon findings or symptoms, abnormalities, disease surveillance. If medical necessity is not documented, this is considered a potential abuse situation. And I'm going to tell you guys, we see this a lot, all right, when we're doing reviews. And the pathologist is also hanging out there to dry too. They need a reason for the specimen because screening is not an approved diagnosis code for pathology specimens. All right, they definitely need to know why this is being done. All right, and your endoscopy report starts the whole process. You need to have medical necessity for any biopsies that you do. And then the pathologist also has to have the medical necessity for the biopsy to support their evaluation of the specimen. So important, guys. And our guidelines have always been if there is something that doesn't match, if it's contradictory, when you're reading through it, you've got screening and you've got biopsies of normal tissue done, you should hold that claim. You should go back and talk to your providers. You should pull records to see what's going on before you submit that charge. All right, so what modifier is added when a snare polypectomy is done in the transverse colon, but the scope was unable to get beyond the hepatic flexure? Is it A, 22? Is it B, 53? Is it C, 52? Or is there no modifier necessary? It is 52. Remember, it goes on a therapeutic procedure. So when there's a therapeutic procedure done during a screening or during a diagnostic colonoscopy, either one, and you don't get to the cecum or the end of the line, then the 52 is appropriate. 53 is only done when you're looking and not touching. Okay. Visit to prior to screening, and we kind of cover this in the Q&A. All right, so this is 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 colonoscopy. All right, so this is what we were talking about before, and this actually was established in 2006. On July 1st, 2016, HICPIC-2, which is a pre-procedure consultation, was established to determine if the patient is healthy enough for the procedure and explain the process to the patient, including the required prep, all of which are necessary to protect the health of the patient. All right, so this is what we were talking about before, HICPIC code S0285 was established. It's approved by UHC, Cigna, Aetna, Anthem, Humana, and some of our other major payers as well. Most of the Blue Collapse and Blue Shield plans also cover this code, and Kristen mentioned this earlier, only approved diagnosis codes are Z1211, Z80.0, and Z83.71. Notice that Medicare does not cover it, and Medicaid may not cover it. If these plans are not covered by the payers other than Medicare, they may allow the 99202 codes to be established with these diagnosis codes. So again, you have to look at payer plans to see what they'll accept. So Medicare does not cover the visit prior to screening or surveillance, and consider this part of the pre-workup associated with the procedure. Mentioned this before, the only time you can bill a visit to Medicare is when you address something unrelated, right? I said they may be at high risk for screening due to other conditions. All right, and I think that was the question, if this patient has COPD, if they're on medications, et cetera. Unfortunately, this consideration is given to these risk factors. It's inclusive in the usual preoperative work associated with this procedure. So the only way that you can actually bill a visit for Medicare, and even some of the commercial payers as well, is if you're actually managing those diagnosis codes, those managing those conditions, right? So it's like, does Medicare pay for it? No. Medicare replacements? No. Commercials? Yes. Okay, and some of them will actually pay for a Z1210 or Z1212, in addition with Z8379 for, you're right. ICD-10 hints. All right, so Z1211, this just means that the patient has screening. They're not symptomatic. Z08 and Z09. Kristen was talking about this earlier. She's got information in her presentation as well. The Z08 means encounter for follow-up exam after completed treatment for willingness neoplasm. It's primary to any ICD-10 code that begins with Z85. And Z09 is primary to any code that begins with Z86 to Z87. All right, we know that Cigna wants this. We also know that Palmetto and Meridian want these as primary as well, the Z08 or Z09. Z12 and Z80, which means average risk screening for family history. All right, so we do have some payers will automatically deny Z1211 based upon age if the patient is younger than age 45. We need to also create a spreadsheet by payer determined. We know that the guidelines, the ACA guidelines, pretty well mean that screening begins at age 40 or 10 years younger than the person with colon cancer. So it's so important that the age of the relative be documented in the common field for anybody under the age of 10. So if they're, say, 38 years of age, you would put in their mother diagnosed with colon cancer at age 48. Whether the patient has family history or personal history, we still need to have reauthorization to make sure that the eligibility is allowed for this as considered part of AB preventive service benefit. Most payers seem to allow family history as a preventive benefit. All right, so it's up to your physician and provider to be clear in their documentation, whether this is screening or diagnostic. If it's not clear, discuss this with them, have them make the appropriate legal corrections if required. I said this a couple of times already, make sure preauthorization and eligibility are verified, patient is fully informed of their responsibility. And if you make the patient responsible to check for preauthorization, it's probably not going to get done. All right, so really important that you do this, that you have a financial counselor in your office or somebody that definitely will check for eligibility. It'll cost you practice money if you do not. Make sure to sign the screening diagnoses in the proper ranking position. Check your MACs, the local coverage determinations, policies for updates and coverage. Always check your ELBs for all denial reasons, because sometimes it's just not clear as to why claims are pended. And make sure, and I think this is number one, whether you post this on your websites, whether you have information posted in your office, when you're doing scheduling, et cetera, you make sure that you give the patients the information verifying the differences between screening, high-risk screening, surveillance, and diagnostic procedures. A lot of your patients do not understand the differences. And we also know that we have issues with our primary care providers understanding differences on this as well. All right. Thank you, guys. And at this point, I'm going to turn this over to Kristen.

screening colonoscopy

diagnostic colonoscopy

Affordable Care Act

billing and coding options

high-risk surveillance

modifiers

medical necessity