2026 Gastroenterology Reimbursement and Coding Update (On-Demand) | November 2025-Screening versus Surveillance Colonoscopy

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This presentation by Kathleen Mueller from AskMueller Consulting clarifies distinctions and coding guidance for screening versus diagnostic colonoscopy, focusing on CMS updates, billing, and policy implications.<br /><br />Key CMS 2025 updates include revisions in ICD-10 codes for personal history of polyps, expanding colorectal cancer (CRC) screening options such as the FDA-approved Shield blood test and CT colonography, with specific frequency allowances. Medicare now covers these tests for average-risk patients 45-85 years old.<br /><br />The Medicare Screening Colonoscopy Loophole, closed by legislation starting in 2023, phases out patient cost-sharing when a screening colonoscopy converts to diagnostic after polyp detection, reaching full CMS coverage by 2030.<br /><br />Colonoscopies are categorized as screening (asymptomatic patients, every 10 years), diagnostic (symptoms like bleeding or pain), or surveillance (patients with personal history of polyps, cancer, or inflammatory bowel disease). Surveillance is often not covered as preventive by commercial payers, though Medicare covers it similarly to screening.<br /><br />For patients with inflammatory bowel disease, colonoscopy billing depends on procedure intent: standard screening without biopsies qualifies for high-risk screening codes; random biopsies indicate diagnostic intent.<br /><br />The Affordable Care Act mandates coverage without patient cost-sharing for preventive services, including colorectal screening starting at age 45, and follow-up colonoscopy after positive stool tests (e.g., FIT, Cologuard). Some health plans remain grandfathered and may not fully comply.<br /><br />Billing codes used include G0121 for average-risk screening and G0105 for high-risk screening, with various modifiers:<br />- KX for follow-up screening colonoscopy after positive stool tests, avoiding cost-sharing.<br />- PT to convert screening to diagnostic colonoscopy for Medicare, waiving deductible but patient responsible for co-pay.<br />- 33 to designate preventive service on commercial claims.<br />- 52 and 53 for reduced or discontinued procedure reporting.<br /><br />Important billing practices include proper documentation of screening intent, correct use of codes/modifiers, verification of patient coverage and eligibility, and clear patient education about differences between screening, diagnostic, and surveillance colonoscopy. Accurate clinical documentation and adherence to payer policies help prevent denials and ensure appropriate reimbursement.

Asset Subtitle

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

Keywords

colonoscopy

screening colonoscopy

diagnostic colonoscopy

CMS 2025 updates

ICD-10 codes

colorectal cancer screening

Medicare coverage

Affordable Care Act

billing codes

patient cost-sharing