Part B Insider (Multispecialty) Coding Alert

Reader Question:

Colonoscopy Won't Be Payable for Acute Diarrhea

Published on Mon Apr 11, 2016

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Question: Our patient had diarrhea and the physician ordered a colonoscopy. Now the payer is denying the charge. Can you advise?

Codify Subscriber

Answer: If your physician performs or orders a colonoscopy for the following conditions, keep in mind that they aren’t typically payable. You should have additional documentation that indicates the medical necessity of the procedure when you submit your records for review by the payer. These conditions are as follows:

Chronic, stable, irritable bowel syndrome or chronic abdominal pain. There are unusual exceptions in which the colonoscopy may be done once to rule out organic disease, especially if symptoms are unresponsive to therapy.
Acute limited diarrhea.
Hemorrhoids.
Metastatic adenocarcinoma of unknown primary site in the absence of colonic symptoms when it will not influence management.
Routine follow-up of inflammatory bowel disease (except for cancer surveillance in chronic ulcerative colitis).
Routine examination of the colon in patients about to
undergo elective abdominal surgery for non-colonic disease.
Upper GI bleeding or melena with a demonstrated upper GI source.

Check with your insurer for specifics because each payer may have its own covered diagnoses, but the list above is a good starting point to investigate further if you see these diagnoses without additional reasons on a colonoscopy order. If your patient has one of these conditions and the doctor believes that the colonoscopy is medically necessary and the patient agrees to undergo it, ask the patient to sign an advance beneficiary notice and explain to her that her insurer may not cover it.