Screening Colonoscopy Not Covered by Insurance Company
Q: I have had a problem getting my colonoscopy covered.
A: According to the Affordable Care Act (ACA) insurance companies are supposed to cover a screening colonoscopy without any out-of-pocket costs. While a screening colonoscopy is supposed to start at the age of 45, people with Lynch syndrome can and should start in their 20s.
Occasionally a diagnostic colonoscopy is ordered instead of a screening colonoscopy. A diagnostic colonoscopy is only supposed to be ordered if there was a problem such as diarrhea, bleeding, pain, or from an abnormal test like a stool test, x-ray, etc. If that is done patients may have to pay thousands of dollars to cover their deductible, copayments, etc. It is important that the physician’s office file the procedure with the correct codes, which is often confusing.
A standard screening colonoscopy has a CPT billing code of 45378. Sometimes when a physician discovered an abnormality during the procedure the colonoscopy is changed to a diagnostic colonoscopy which is not fully covered. To help maintain as much coverage as possible for the preventive colonoscopy, if a biopsy was done during a procedure that was meant for a screening test, a modifier code of 33 should be added and it should not be changed to a diagnostic colonoscopy. Thus the submitted code would be 45385-33, which means a screening colonoscopy with a polyp removal. That allows for an additional procedure while still qualifying for a screening. The modifier code of 33 is used for commercial insurance. If the patient has Medicare, a code of PT is used instead.
So the insurance company knows the patient has Lynch syndrome, it is important that the physician’s office submits a diagnostic or ICD-10 code of Z15.09. This is used to signify Lynch syndrome (genetic susceptibility to other neoplasms). This classifies the person as a high-risk for colon cancer, which supports colonoscopies at an earlier age and more often.
is the polyp biopsy also covered by insurance?
If a biopsy is done there is an additional charge. It is obviously medically indicated so should be covered under routine insurance, but it is not part of the “free colonoscopy” under the Affordable Care Act. Therefore normal deductibles and insurance percentage will apply. However, removing an abnormal polyp may prevent cancer from starting. So there is a substantial cost savings.
My primary care doctor has insisted that it should be coded as diagnostic, as I am under 45 (under 30). He said he talked with a GI, but I cannot confirm the GI is familiar with Lynch.
I have received pushback trying to get it coded as preventative/screening despite citing the above. How would you proceed?
The definition of a diagnostic test is to investigate symptoms or other abnormalities while a screening definition implies there are no symptoms or test abnormalities to suggest an active problem. Having Lynch syndrome classifies a person in the “high risk” group for getting cancer but having does not mean you have a test abnormality to suggest a diagnostic procedure. You can ask your physician’s office to change it and let them know if they do not you will call the insurance company since they are not coding it properly. They will then have to explain their billing practices to them. THe physician’s office will get paid the same, however your bill could be reduced substantially, since most of the procedure and anesthesia may be covered 100% per the Affordable Health Act (Obamacare).