![]() Medicare does not waive the co-pay and deductible when the intent of the visit is to perform a diagnostic colonoscopy. However, diagnostic colonoscopy is a test performed as a result of an abnormal finding, sign or symptom. Preventive Services Task Force (USPSTF) and process the claim as screening. Read more about diagnosis coding for screening colonoscopyĪs part of the Affordable Care Act (ACA), Medicare and third-party payers are required to cover services given an A or B rating by the U.S. Whether a polyp or cancer is ultimately found does not change the screening intent of that procedure. A patient with rectal bleeding and anemia who is has a colonscopy is having a diagnostic colonoscopy.Īs such, “screening” describes a colonoscopy that is routinely performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps. A diagnostic test is done in response to a sign or symptom, to investigate and diagnosis a condition. It is defined by the population on which the test is performed, not the results or findings of the test. What is the Difference between a Screening Test and a Diagnostic Colonoscopy?Ī screening test is a test provided to a patient in the absence of signs or symptoms based on the patient’s age, gender, medical history and family history according to medical guidelines. But, what if the surgeon or gastroenterologist takes a biopsy or removes a polyp? How is that billed, and with what modifiers and diagnoses? CodingIntel provides detailed medical coding resources to physicians and their staff to help them accurately code for their services, including colonoscopy coding guidelines with using CPT codes, modifiers PT and 33, and diagnosis coding. A screening test with an A or B rating from the US Preventive Services Task Force, should have no patient due amount, since the Affordable Care Act (ACA) was passed. Screening colonoscopy is a service with first dollar coverage. If history is a guide, CMS will issue coding rules regarding this early in 2023. How practices will bill this to Medicare (using screening HCPCS codes or diagnostic CPT codes) is not described in the rule. As noted earlier in the rule, the outcome of our more appropriate and complete approach to CRC screening will be that, in many cases, beneficiary cost sharing for both the initial non-invasive screening stool-based test and the follow-on screening colonoscopy test will not apply because both tests will paid at 100 percent (no applicable copayment percentage) as specified preventive screening services under the statute.” “We also are exercising our authority in section 1861(pp)(1)(D) of the Act to expand coverage of CRC screening tests to include a follow-on screening colonoscopy after a noninvasive stool-based test returns a positive result. For Medicare, starting 1/1/23, that follow up test will be processed as a screening test, not subject to any patient due amount. Before 2022, the colonoscopy was processed as a diagnostic test, exposing the patient to deductible and co-insurance amounts. when a patient has a non-invasive screening test ( FOBT or MT-sDNA test) and has a positive result, the subsequent colonoscopy will be processed as a screening test, not diagnostic. Just as exciting and welcome is the solution to a longstanding problem. Patients can begin screening for colorectal cancer (CRC)at 45, without being charged a copay or deductible. CMS is lowering the age for screening from 50 to 45. The 2023 Physician Fee Schedule rule released 11/1/22 brings good news. From 2030 onwards, there is no coinsurance due. Co-insurance for planned colorectal screening services that become diagnostic or therapeutic will be phased out to 0 between 20.In 2022, the co-insurance amount was 20%. But, Medicare still charges co-insurance for screening colonoscopies that convert to diagnostic or therapeutic services, ie, removal of a polyp. The ACA prohibited Medicare from charging a deductible for screening colonoscopies that converted from screening to diagnostic.In that case, using the correct modifiers and sequencing the diagnosis codes correctly can increase the likelihood that the payer will still process the service as a screening, but there are no guarantees.But if the physician does a diagnostic procedure (biopsy) or therapeutic procedure (removal of polyp), the procedure is no longer considered a screening, resulting in a patient due balance. Both deductible and co-insurance are waived. A screening colonoscopy should have no patient due amount for an insured patient.An Overview of Colonoscopy Coding Guidelines
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