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Insurance question on colonoscopy: screening or diagnostic?
I was diagnosed with early stage NET and had a follow-up endoscope ultra sound to confirm that my colon was clear of cancer cells last year, but was told to go back for a colonoscopy in a year. I just did that, but the claim treated this visit as diagnostic instead of preventive. should this be preventive or diagnostic?
Thank you, Mike
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I go back for colonoscopy every 3 yrs. Was told a routine colonoscopy is preventative; going back more often than routine is diagnostic. Would think yours would be the same. I'd talk to your dr.... Coding might be all that needs to be changed when they send their bill to yout insurance co.
I would think diagnostic, but you should appeal with your doctor that order it to justify the procedure. In our experience, it usually is covered once doctor files that information. Good luck!
In my experience your insurance company benefit will vary for screening/preventive procedures and diagnostic procedures. Screening/preventive coverage is at a higher level than diagnostic procedures. A screening colonoscopy will be billed with a G0105 or G0121 code with the latter code for high risk patients. A diagnostic procedure, for symptomatic patients or in the course of treatment, will be billed with a CPT code (45378-45398.)
I would argue that you had screening procedure due to high risk, code G0121 unless you were symptomatic.
The logic of this distinction in coverage baffles most of us.
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2 ReactionsI had the same thing happen to me on my first colonoscopy (i.e. found a NET ). When scheduling the colonoscopy make sure they know you are on a 1 year or 3 year high risk screening per your doctor. Should be a screening if not symptomatic. I am also a medical coder. I would ask that your colonoscopy be reviewed and recoded as a screening. If need be perhaps you doctor can confirm that to the coder or billing office. They will need to submit a new claim with the new codes to your insurance company. Don't pay until that has been done.
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1 ReactionThank both of you, @tomatlanta and @cewald62! Vey helpful and I will call the doctor's office and request a review. Best, Mike
What did you find out from the doctor's office, @mikecincy?
They would initiate a review of the claim and temporarily suspend the processing of the bills. The review process is expected to take approximately 30-45 business days. Additionally, I contacted my insurance company and was informed that I have the option to appeal the claims if the review upholds their initial assessment.
My GI doctor is associated with GastroHealth, which operates in multiple states. The individuals handling the calls are part of a different group and are likely located out of state.