Outpatient Facility Coding Alert

Question: What are the conditions when colonoscopy cannot be billed separately?

New Jersey Subscriber

Answer: Yes, there are conditions when a gastroenterologist performs colonoscopy but the service will not be covered. You should have additional documentation that indicates the medical necessity of the procedure when you submit your records for review by the payer.

According to medical experts, a few of these conditions include:

• Hemorrhoids
• Acute limited diarrhea
• Chronic, stable irritable bowel syndrome (IBS) or chronic abdominal pain (though there are some exceptions with this condition in certain circumstances)
• Routine follow-up of inflammatory bowel disease (IBD) (except for checking on cancer related to chronic ulcerative colitis)
• Upper GI bleeding 
• Routine colon exam for a patient scheduled for elective abdominal surgery for non-colonic disease.

---