HELPING YOU TO UNDERSTAND YOUR MEDICAL TREATMENT TERMS AND NAVIGATING INSURANCE BENEFITS
Colonoscopy: Screening or Diagnostic?
Your doctor has referred you to GastroIntestinal Healthcare (GIH) for a screening colonoscopy, but there may be a misunderstanding of the word “screening”. Before your procedure, our doctor performing the colonoscopy will determine what category of colonoscopy you will be having. With this important information, we will then contact your insurance company and find out what your estimated financial responsibility will be according to your specific policy coverage.
Colonoscopy Categories:
Preventative Colonoscopy Screening Diagnosis: Patient has no gastrointestinal symptoms either past or present. Is 45 or older, has no personal or family history of GI disease, colon polyps, and/or colorectal cancer. The patient has not undergone a colonoscopy within the last 10 years.
Surveillance/High Risk Screening Colonoscopy: Patient does not have gastrointestinal symptoms either past or present. Patient does have either a personal history or family history of GI disease, colon polyps, and/or colorectal cancer. Patients in this category are required to undergo a colonoscopy surveillance at shortened intervals, usually every 2 to 5 years.
Diagnostic/Therapeutic Colonoscopy: Patient has either past and/or present gastrointestinal symptoms, polyps, GI disease, iron deficiency anemia and/or any other abnormal tests.
Common Questions:
Can the physician change, add, or delete my diagnosis so that I can be considered eligible for colon screening? NO! The patient encounter is documented as a medical record from information you have provided, as well as what is obtained while taking your pre-procedure history and assessment. It is a binding legal document that cannot be changed to facilitate better insurance coverage. Patients need to understand that strict government and insurance company documentation and coding guidelines prevent a physician from altering a chart or file for the sole purpose of coverage determination. This is considered insurance fraud and is punishable by law with fines and/or jail time.
What if my insurance company tells me that the doctor can change, add, or delete a procedure or diagnostic code? This happens a lot. Often the representative at the insurance company will tell the patient that “if the doctor had coded this as a screening, it would have been paid differently”. However, further questioning of the representative will reveal that the “screening” diagnosis can only be changed if it applies to the patient. Remember that many insurance carriers only consider a patient over the age of 45, with no personal or family history, as well as no past or present gastrointestinal symptoms, as a “screening –V76.51.”
If you are given this information, please document the date, name and phone number of the insurance representative. Next, contact our billing department, who will perform an audit of the billing and investigate the information given. Often the outcome results in the insurance company calling the patient back and explaining that the member services representative should never suggest physicians change their procedure billing for better benefit coverage.
When my insurance company says that I am covered at 100%, does this mean that I personally will have nothing to pay? Sometimes you will have to pay something, depending on your particular policy and benefits. You may still have a deductible amount and/or co-pay/co-insurance after the insurance company has paid the doctor. In that case, the procedure may be covered at 100% – after you meet your co-insurance/co-pays and deductible are applied.
