Wiki Anthem BCBS - PT Fam Hx Colon Ca and Personal Hx of Colon Polyps

[missyah20]

Hello All,

I feel like not matter how often I code or see Colonoscopy cases I still end up with some scenarios that confuse me. We have a patient who has a home plan of Anthem BCBS of Ohio. This patient had a previous colonoscopy 5 years ago. They have a Family Hx of Colon cancer in a First degree Relative (mom) and a Personal Hx of Adenomatous Polyps. Per the Anthem Colonsocopy Clinical UM Guideline CG-SURG-01 the Personal HX would make this a Surveillance, but the Fam hx would be a High risk screening. Or because they now have the Hx of adenomatous polyps they are always considered surveillance under Anthem even with the family history of colon cancer?

Would this Colonoscopy be billed as a Surveillance or a Screening?

https://www.anthem.com/medpolicies/abc/active/gl_pw_c119565.html

Surveillance Colonoscopy in At-Risk Populations
Adenomatous Polyps or Sessile Serrated Polyps (SSP): Those who have a personal history of one or more adenomatous polyps or SSPs removed at colonoscopy are managed according to the findings (that is, considering number of polyps and pathology). Colonoscopy may be appropriate in any of the following:

1. For those with 1 or 2 small (less than 1 cm) tubular adenomas or SSPs without cytologic dysplasia, the first follow-up colonoscopy is appropriate in no less than 5 years; (2, 11, 15, 18, 21) or
2. For individuals with a history of any of the following, the first follow-up colonoscopy is appropriate 3 years after the initial polypectomy:
   1. 3 to 9 adenomatous polyps and/or SSPs; (11, 21, 22) or
   2. Any adenoma or SSP greater than or equal to 1 cm; (11, 21) or
   3. Any adenoma with villous or tubulovillous features; (11, 21) or
   4. Any adenoma with high-grade dysplasia; (11, 21) or
   5. Any SSP with cytologic dysplasia; (2, 11, 15, 18, 21)
      or

Screening Colonoscopy in Higher Risk Populations

1. Family History of Colorectal Cancer or Adenomas:The vast majority of those with increased risk are in this category. Screening colonoscopy is appropriate for a person with a family history indicating any of the following:
   1. One first degree relative (parent, sibling or child) with colorectal cancer diagnosed at any age; (2, 18, 22, 29, 45)
      1. Colonoscopy beginning at age 40; (2, 18, 22, 29, 45) or
      2. Colonoscopy beginning at an age 10 years younger than the age at diagnosis of the youngest affected relative, whichever comes first; (2, 18, 22, 29, 45) and
      3. For this specific group, colonoscopy may be repeated no less than every 3 years depending on findings; (2, 18, 22)
         or