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

Video Transcription

Video Summary

The video provides a comprehensive overview of colonoscopy procedures, billing, and coding updates, particularly focusing on CMS guidelines and colorectal cancer screening. It emphasizes the importance for billing/coding staff to observe endoscopy procedures firsthand to better understand providers' work. Key topics covered include CMS updates, types of colorectal cancer screenings (diagnostic, high-risk surveillance, average risk), relevant ICD-10 and HCPCS codes, and the Affordable Care Act’s (ACA) impact on coverage.<br /><br />Significant changes include new screening blood tests (e.g., epiprocolon, SHIELD) approved for Medicare every 3 years for asymptomatic, average-risk patients aged 50-85, and detailed frequency limits for CT colonography. The video also explains the “loophole” closure in billing: if polyps are removed during screening colonoscopy, patient out-of-pocket costs gradually decrease to zero by 2030.<br /><br />It clarifies screening vs diagnostic vs surveillance colonoscopy distinctions, stressing accurate coding and documentation (e.g., specifying anemia types, family history, biopsy rationale) to avoid denials. The Affordable Care Act mandates no cost-sharing for screening starting at age 45, but some grandfathered plans and Medicare Advantage may differ. The use of modifiers (KX, PT, 33, 52, 53) is detailed for various billing scenarios.<br /><br />Finally, it urges verifying patient benefits, preauthorizations, and educating both providers and patients about coverage to minimize claim denials and confusion around screening colonoscopy procedures.

Asset Subtitle

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

Keywords

colonoscopy procedures

CMS guidelines

colorectal cancer screening

ICD-10 codes

HCPCS codes

Affordable Care Act

screening blood tests

billing and coding updates