Question Screening vs Surveillance Colonoscopy

MelBarclay

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Our office and facility need clarification on colonoscopy coding for polyp surveillance. Some are saying it should be a high risk screening due to polyps (CPT 45378, DX: Z12.11, Z86.010) and patient's insurance will pay 100%. The other opinion is that it should be a surveillance colonoscopy due to polyps (CPT 45378, DX: Z86.010) and patient's deductible/co-insurance would apply.

Cannot find specific CMS guidelines in regards to this. Any help would be appreciated!!

Melanie
 

thomas7331

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This is a confusing area that's made worse by the fact that payers, coders and providers may not always agree exactly on the definitions of what constitutes a screening services.

But for Medicare patients, this is spelled out clearly and both of these are considered screening services (though you would bill the HCPCS codes instead of the CPT code: G0105 for the colonoscopy on a high risk patients, G0121 for non-high risk patients). Copays and deductibles are waived in either case: https://www.cms.gov/Medicare/Preven...vices/MPS-QuickReferenceChart-1.html#COLO_CAN

For commercial patients, you will need to review the payer policies and plan benefits for the individual patients. The ACA law requires that screenings for normal risk patients be covered at 100%, but individual payers and plans can elect to pay a colonoscopy for a high risk patient as a diagnostic procedure and apply these to a copay or deductible. UHC, for example, has such a policy for their commercial plans. However, it's never as simple as that, and individual employers can choose to cover the procedure in full for their employees, so even with a policy in place, it's not a guarantee that this is how the claim will process. Unfortunately, these often just have to be looked at on a case by case basis.
 

MelBarclay

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San Antonio, TX
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Thanks for your input and the CMS link. Looks like we need to get clarification from all our commercial payers.

I just caught a note that my doctor put "high risk screening surveillance" b/c of all the confusion and difference between payers. :)

Thanks Again!
 
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