Patients often want to know if their colonoscopy will be billed under a "screening" code, because screening colonoscopies are covered more completely by their insurance.
We perform three kinds of colonoscopies, and they are usually billed out as follows:
|Screening:||Always bills with a screening code|
|Surveillance:||Sometimes bills with a screening code|
|Diagnostic:||Never bills with a screening code|
You can find more information about each of those three kinds of procedure below. If you aren't sure which type applies to your case, or have any other billing questions, please call our billing line at: 214-501-1194.
Billed as Screening? Always
A colonoscopy is a traditional screening type if you meet all of the following criteria:
- You are 50 years old, or older.
- You have not had a colonoscopy in the last 10 years.
- You do not have any gastrointestinal symptoms, either past or present (Examples: rectal bleeding, abdominal pain, change in bowel habits, constipation, diarrhea)
- You do not have a personal history of colon cancer, colon polyps, gastrointestinal disease (Examples: colitis, Crohn's), etc.
- You do not havre a family history of colon cancer, colon polyps, gastrointestinal disease, etc.
Billed as Screening? Sometimes
Your colonoscopy is considered Surveillance/High-Risk if you meet the following criteria:
- You have a personal history of colon polyps, or colon cancer
- You have a personal history of inflammatory bowel disease, including Crohn's, colitis, etc.
- You have a family history (meaning: first-degree relative) who has had colorectal cancer, adenomatous polyps, etc.
In many cases, coding guidelines allow us to code your follow-up/recall colonoscopy as screening for surveillance/high risk reasons. We do this by using the diagnosis code for screening (Z1211) followed by a modifier giving the reason for the colonoscopy (for example: history of colon cancer). There are also situations that preclude us from billing a Surveillance/High-Risk colonoscopy as screening. If you have current issues such as rectal bleeding, abdominal pain, etc., then the colonoscopy must be diagnostic.
Also Note: Benefits vary widely for "family history." You will need to check with your insurance company to see how it is covered (the benefit often applies to your deductible and co-insurance expenses).
Billed as Screening? Never
Your colonoscopy will be billed as diagnostic rather than screening if you meet the following criteria:
- You have symptoms or a diagnosis which requires further evaluation. Examples include: rectal bleeding, abdominal pain, change in bowel habits, constipation, blood in stool, anemia of unknown cause, diarrhea.
Be aware that, once we submit the claim to your insurance, they still have leeway to process it as a diagnostic colonoscopy even if we submitted it as screening. There are hundreds of insurance plans, each with their own criteria, so it is impossible for us to tell you with certainty how your insurance company will interpret your claim. Also depending on your insurance, you may still be responsible for a portion of the charges approved by your insurance plan.