Visit Prior to Screening Colonoscopy

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Since a Visit Prior to Screening colonoscopy is a non-covered (not billable) service should we continue to submit the claim with GY Modifier (Notice of Liability Not Issued, Not Required Under Payer Policy) - this modifier is used to obtain a denial on a non-covered service. Use this modifier to notify Medicare that you know this service is excluded. Would love to know how other practices are handling this claim. Thank you.
 

thomas7331

True Blue
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Our practice made the decision that these should be no-charge visits. For one thing, there isn't really an appropriate code to use - if the visit is only for pre-op for the screening colonoscopy, an E&M code is not appropriate because you don't have a chief complaint or any medical necessity to support the visit. The pre-operative work for a healthy patient with no symptoms is pretty routine and would be encompassed in the global fee. In looking into how other practices handled this, we found that many GI practices had a screening questionnaire that the staff could go through with the patient, or the patient could complete on line, which would determine the patient's suitability for the colonoscopy. Then if something abnormal was identified on that questionnaire that required a physician visit prior to the procedure, it would be scheduled and an office visit would be appropriate since there was a comorbidity or other health issue that met the medical necessity for a physician encounter.
 

helenadutoit

Networker
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53
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Tracys Landing, MD
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Since a Visit Prior to Screening colonoscopy is a non-covered (not billable) service should we continue to submit the claim with GY Modifier (Notice of Liability Not Issued, Not Required Under Payer Policy) - this modifier is used to obtain a denial on a non-covered service. Use this modifier to notify Medicare that you know this service is excluded. Would love to know how other practices are handling this claim. Thank you.

A colonoscopy does not have a global period, or at the most, 10 days. On the same day of the procedure, an E/M service would be inappropriate, since the E/M pertains to the screening procedure, a modifier 25 would therefore be inappropriate to indicate a separate and distinctly different encounter.

If a patient is referred to a GI physician, for a chief complaint such as "I haven't had a colonoscopy for the past ? years, or never before", the GI physician should do a E/M work-up to ascertain whether the patient is an appropriate candidate for a screening/diagnostic procedure.

For CMS a new patient encounter should be used, since Medicare does not acknowledge consult. Some private carriers still accept consults and a consultation encounter could be billed for.

I am not sure whether you are referring to a PCP or a GI physician. I would think a PCP decides to send a patient during a physical, age appropriate exam. The PCP can bill and get reimbursed for the physical exam as normal and the patient will go to a GI physician for the procedure without an E/M prior to the procedure or get a short History and exam on the DOS, which cannot be billed for.
 

ssmyers

New
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Screening visit for Cologuard

I was wondering if anyone has had any experience with billing for an office visit simply to order the Cologuard test. The patient's PCP referred the patient here because the PCP was not comfortable ordering the test. We of course do not bill for an office visit if a patient is seen prior to a colonoscopy, but since we are not performing a colonoscopy, we are looking to potentially bill for this office visit. There is no diagnosis other than screening. The provider saw the patient, went over histories, etc., and ordered the Cologuard. Does anyone have any input on this?
 

helenadutoit

Networker
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Tracys Landing, MD
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Office visit for cologuard test

If there is no other reason to do this test, then you should report the screening code. If the patient has a family history, it will of course also be helpful. There must be a reason for the test, if not, screening is the answer.
 
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