Colonoscopies - surveillance vs. screening

[bethb]

Hello. To me, coding guidance for surveillance colonoscopies is murky, at best. How are you all coding and billing surveillance colonoscopies for commercial insurances? i.e. repeat colonoscopy for a past finding (polyps) Surveillance colonoscopies are usually done at more frequent intervals than screenings. Do you code and bill surveillance with a -33 (or -PT if applicable)? My understanding is that surveillance is not a screening and therefore should not be coded as a screening for commercial insurances. We have had a few patients angry because they are receiving deductible / co-insurance bills for surveillance colonoscopies. The insurance is telling them we are coding them incorrectly Our notes specifically state "surveillance"; no verbiage of "screening" so therefore, no screening diagnosis or screening modifiers are used. Anyone have advice or guidance on this? Is there any clear statement that a surveillance is to be coded as a screening? Thanks in advance!!

 

[Pam Warren]

Surveillance can be a screening, if there's no symptom or condition that's being managed. So if a patient is a high risk for colon cancer because of previous polyps that have been removed (no current symptoms), any further colonoscopies would be screening. IF the patient has a condition (such as continued rectal bleeding) that is current, then you would not code a screening colonoscopy. Here's a link to coding rules from gastro.org. Medicare also has some information that you can use.

https://gastro.org/practice-resources/reimbursement/coding/coding-faq-screening-colonoscopy/#:~:text=What's%20the%20right%20code%20to,decompression%20%5Bseparate%20procedure%5D)

 

[Rpace18]

Often it depends on the insurance guidelines, most insurance policies cover screening 1x every 10 yrs. Though the colonoscopy is considered medically necessary to have sooner than the 10 yrs if polyps found in previous colonoscopy; it often falls under diagnostic/medical with the insurance and the pt will have oop responsibility (ded, coins or copays) Often i find the insurance tells pt its billed incorrectly to appease pt, when in fact those are the insurance guidelines. Also,

 

[bethb]

Surveillance can be a screening, if there's no symptom or condition that's being managed. So if a patient is a high risk for colon cancer because of previous polyps that have been removed (no current symptoms), any further colonoscopies would be screening. IF the patient has a condition (such as continued rectal bleeding) that is current, then you would not code a screening colonoscopy. Here's a link to coding rules from gastro.org. Medicare also has some information that you can use.

https://gastro.org/practice-resources/reimbursement/coding/coding-faq-screening-colonoscopy/#:~:text=What's%20the%20right%20code%20to,decompression%20%5Bseparate%20procedure%5D)

Hello and thank you for your reply and link.

 

[bethb]

Often it depends on the insurance guidelines, most insurance policies cover screening 1x every 10 yrs. Though the colonoscopy is considered medically necessary to have sooner than the 10 yrs if polyps found in previous colonoscopy; it often falls under diagnostic/medical with the insurance and the pt will have oop responsibility (ded, coins or copays) Often i find the insurance tells pt its billed incorrectly to appease pt, when in fact those are the insurance guidelines. Also,

Hi and thank you for your reply. I'm stuck at past history of polyps.. if a patient presents for a surveillance colonoscopy due to a past history of a polyp, is that previous polyp considered a "finding" which commercial insurances would consider non-screening criteria? Even though the previous polyp(s) was removed, how many commercial insurances feel this is a "finding" and therefore consider surveillance colonoscopies to be diagnostic? There absolutely needs to be clearer guidelines for surveillance procedures.

 

[Rpace18]

Hi and thank you for your reply. I'm stuck at past history of polyps.. if a patient presents for a surveillance colonoscopy due to a past history of a polyp, is that previous polyp considered a "finding" which commercial insurances would consider non-screening criteria? Even though the previous polyp(s) was removed, how many commercial insurances feel this is a "finding" and therefore consider surveillance colonoscopies to be diagnostic? There absolutely needs to be clearer guidelines for surveillance procedures.

Yes, the DX code Z86.010 is used as the reason for the colonoscopy. I know most Aetna/UHC/Cigna and some BCBS don't consider personal HX of polyps to be considered screening. If they covered the last colonoscopy within 10 yrs the patient is not eligible for a 100% screening colonoscopy for another 10 yrs. The "surveillance colonoscopy" is considered medically necessary but not a screening service, if polyps were found in the last colonoscopy. Depending on the particular insurance they have their guidelines as to how often they deem it medically necessary to follow up for a surveillance colonoscopy (2-5 yrs) but it most likely will still apply towards pts benefits as diagnostic, since they only cover a screening every 10 yrs. I hope this answers your question, and i made sense lol

 

[bethb]

Yes, the DX code Z86.010 is used as the reason for the colonoscopy. I know most Aetna/UHC/Cigna and some BCBS don't consider personal HX of polyps to be considered screening. If they covered the last colonoscopy within 10 yrs the patient is not eligible for a 100% screening colonoscopy for another 10 yrs. The "surveillance colonoscopy" is considered medically necessary but not a screening service, if polyps were found in the last colonoscopy. Depending on the particular insurance they have their guidelines as to how often they deem it medically necessary to follow up for a surveillance colonoscopy (2-5 yrs) but it most likely will still apply towards pts benefits as diagnostic, since they only cover a screening every 10 yrs. I hope this answers your question, and i made sense lol

Yes, this absolutely makes sense - I appreciate your input and thank you. I cannot even find screening guidelines, high risk guidelines, etc, for our local BCBS. It is crazy how there is little transparency and guidance with surveillance regimens. I feel bad for the patients who are understanding their surveillance colonoscopy will be covered at 100% but it is not.

 

[Rpace18]

Yes, this absolutely makes sense - I appreciate your input and thank you. I cannot even find screening guidelines, high risk guidelines, etc, for our local BCBS. It is crazy how there is little transparency and guidance with surveillance regimens. I feel bad for the patients who are understanding their surveillance colonoscopy will be covered at 100% but it is not.

You're welcome! Im glad it helped. I work for a Gastro office as a Patient Financial Rep. I speak to pts daily about their benefits for colonoscopy's and EGD's. I have a nice collection colonoscopy guidelines for various payors. If you speak with a Ins representative, some are nice enough to guide you on the local BCBS website as to where to find the preventative guidelines.