Wiki Screening or diagnostic colonoscopy?

[hsmith67]

So a friend had a colonoscopy, first done in 2012, 2 polyps found and removed. Second colonoscopy done 2015 1 polyp found and removed. Third colonoscopy done 6/2021 1 polyp found and removed. Never had any symptoms, melena, etc. Colonoscopy was done at ASC partly owned by the GI that performed colonoscopy. Insurance paid 100% for GI, 100% for anesthesia and now he received bill from ASC for $600. He called insurance and insurance told him GI and anesthesia billed as screening and the ASC billed as diagnostic. He called ASC and biller told him per the guidelines this has to be billed as diagnostic.

Please help set the record straight, who billed correctly? GI/Anesthesia or ASC?

Thanks for any help,
Hunter Smith, CPC

 

[jojokat]

So a friend had a colonoscopy, first done in 2012, 2 polyps found and removed. Second colonoscopy done 2015 1 polyp found and removed. Third colonoscopy done 6/2021 1 polyp found and removed. Never had any symptoms, melena, etc. Colonoscopy was done at ASC partly owned by the GI that performed colonoscopy. Insurance paid 100% for GI, 100% for anesthesia and now he received bill from ASC for $600. He called insurance and insurance told him GI and anesthesia billed as screening and the ASC billed as diagnostic. He called ASC and biller told him per the guidelines this has to be billed as diagnostic.

Please help set the record straight, who billed correctly? GI/Anesthesia or ASC?

Thanks for any help,
Hunter Smith, CPC

If the diagnosis used was high risk screening and/or personal history of polyps, and the GI/Anesthesia both billed as screening, then they most likely added the appropriate modifier to designate that the colonoscopy started as a screening and converted to diagnostic. For the ASC, that would be modifier PT if I am not mistaken. Your friend should request that they refile the colonoscopy with the appropriate modifier to show that it started as a screening and was converted to a diagnostic.

Hope they will refile it appropriately for your friend.

 

[zcometa]

I'm assuming your friend has commercial insurance because $600 is kind of steep for a Medicare coinsurance for an ASC procedure. Were the previous procedures done at the end of the year? (to exclude possible meeting of deductibles and OOP). Did he change insurance companies in between the procedures? (to find out how a screening colonoscopy could be covered multiple times or if his benefits changed which would account for difference in how the procedures were processed). Some policies cover screening colonoscopies <10 yrs (yes, they exist).

 

[MarDee]

So a friend had a colonoscopy, first done in 2012, 2 polyps found and removed. Second colonoscopy done 2015 1 polyp found and removed. Third colonoscopy done 6/2021 1 polyp found and removed. Never had any symptoms, melena, etc. Colonoscopy was done at ASC partly owned by the GI that performed colonoscopy. Insurance paid 100% for GI, 100% for anesthesia and now he received bill from ASC for $600. He called insurance and insurance told him GI and anesthesia billed as screening and the ASC billed as diagnostic. He called ASC and biller told him per the guidelines this has to be billed as diagnostic.

Please help set the record straight, who billed correctly? GI/Anesthesia or ASC?

Thanks for any help,
Hunter Smith, CPC

Hi! Because your friend's first colonoscopy had polyps, this would place him/her in a high risk category. Therefore, screenings or aka surveillance, is payable every two to three years depending on insurance. The ASC should have billed this as a screening. Appending modifier PT or 33 depending on insurance.

 

[LisaAlonso23]

It depends on the insurance. Aetna, Cigna, UHC, and some BCBS consider a patient having a colonoscopy with a history of polyps to be diagnostic and not a screening.