2025 Gastroenterology Reimbursement and Coding Update (Virtual) | November 2024-04

04 - Screening vs Diagnostic Colonoscopy

Pdf Summary

The document is a comprehensive presentation by Kathleen A Mueller, RN, CPC, on the differences between screening and diagnostic colonoscopies, alongside relevant policy updates, billing, and coding practices. <br /><br />Key points include:<br /><br />1. **Affordable Care Act (ACA) and Screening**: The ACA recommends colorectal cancer screening begin at age 45. Medicare coverage for screenings starts at this age beginning January 1, 2023. Various screening methods and tests are available, each appropriate for different conditions and risks.<br /><br />2. **Medicare Loophole and Updates**: Recently, a Medicare loophole was closed to ensure that if a screening colonoscopy turns diagnostic (e.g., polyps are found and removed), patients aren't unexpectedly charged. This change phases out cost-sharing by 2030, with Medicare covering 100%.<br /><br />3. **Differentiation of Colonoscopy Types**: Screening colonoscopies are for asymptomatic patients and are covered by Medicare every 10 years. Surveillance colonoscopies are for those with a history of colorectal issues, and may not be covered as preventive by all payers. Diagnostic colonoscopies are for patients exhibiting symptoms like abdominal pain or bleeding.<br /><br />4. **IBD and Colonoscopy**: For inflammatory bowel disease (IBD) patients, whether a colonoscopy is deemed screening or diagnostic depends on intentions—if random biopsies are taken, it's diagnostic.<br /><br />5. **Modifiers and Coding**: Several modifiers influence billing and patient responsibility, such as modifier PT for procedures turned diagnostic and modifier 33 for preventive services. Correct coding, such as using G0105 or G0121, ensures appropriate billing for screenings.<br /><br />6. **Pre-Screening Visits**: Commercial insurers may cover consultation visits before a colonoscopy as part of the screening process, but Medicare does not.<br /><br />This presentation emphasizes adequately following billing practices and understanding insurance policies to minimize patient financial responsibility and comply with legal requirements.

Keywords

screening colonoscopy

diagnostic colonoscopy

Affordable Care Act

Medicare coverage

colorectal cancer

billing practices

coding modifiers

inflammatory bowel disease

cost-sharing

insurance policies