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

Video Transcription

Video Summary

The speaker uses an endoscopy image to emphasize that coders and billers should observe procedures in an endoscopy center to better understand documentation and coding. The session reviews CMS and Affordable Care Act (ACA) guidance for colorectal cancer screening, including definitions of screening vs diagnostic vs surveillance colonoscopy, correct ICD-10 sequencing, and payer-specific billing rules.<br /><br />Key updates include new 2025 Medicare codes: G0327 for blood-based biomarker screening (average-risk, asymptomatic, ages 50–85, every 3 years) and CT colonography screening frequency rules. The “screening converted to diagnostic” cost-sharing loophole is closing gradually (Medicare patient share decreases until 0% in 2030).<br /><br />The speaker stresses payer variation: some require screening diagnosis first, others require findings first; modifiers matter (PT, 33, KX, 52/53, facility 74). Follow-up colonoscopy after a positive stool test can remain a screening benefit with KX. Pre-screening consults may be covered under ACA using S0285 (commercial plans, not Medicare).<br /><br />Major risk areas include inappropriate “random biopsies” during purported screening, unclear documentation, lack of anemia specificity, misuse of Cologuard in high-risk patients, and failure to verify benefits/authorize and educate patients on potential cost sharing.

Asset Subtitle

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

Keywords

colorectal cancer screening colonoscopy coding

CMS Medicare ACA screening guidance

screening vs diagnostic vs surveillance colonoscopy

ICD-10 sequencing for colonoscopy claims

2025 Medicare code G0327 blood-based biomarker test

CT colonography screening frequency rules

colonoscopy modifiers PT 33 KX 52 53 74

payer-specific billing rules and cost-sharing changes