As the Affordable Care Act (ACA) takes effect, health care providers are experiencing some unintended billing consequences. One procedure that creates confusion for patients as well as providers concerns colonoscopy billing for Medicare patients. Here’s what medical practices need to know about this untidy (and sometimes expensive) little coding snarl.

Screening, Surveillance and Diagnosis

The colonoscopy billing problem arises because Medicare pays differently for “screening” and “diagnostic” colonoscopies. Many apparently healthy patients come in for routine screening, and neither they nor their doctor suspects the presence of any problems. However, the University of Michigan Medical Services notes that routine colonoscopies reveal polyps in 30 percent of men and 20 percent of women over the age of 50. Often, the most efficient medical approach in such cases is to remove the polyp during the colonoscopy, but even if the physician simply notes the existence of a problem, the entire procedure suddenly falls under a different billing category. If medical office personnel aren’t aware that they need to modify their coding to reflect the changed nature of the interaction, the practice will lose money. Furthermore, additional billing complications arise if a patient is currently asymptomatic but has a history of polyps or other gastrointestinal disease.

How to Define Screening

As a result of the Affordable Care Act, your practice is likely to see more patients making appointments for preventive services. The new health care law stipulates that each person may receive a free colonoscopy according to a schedule set by the U.S. Preventive Services Task Force. Patients between the ages of 50 and 75 with no symptoms or history of polyps, colon cancer or gastrointestinal disease are now encouraged to have one free screening colonoscopy every 10 years. If their screening reveals no problems, Medicare will reimburse the practice for the full procedure, and the patient has no deductible or co-pay.

“Surveillance” is Different from “Screening”

According to AAPC, a professional organization of medical coders, it’s crucial that physicians as well as billing staff distinguish between surveillance and screening. The term “screening” is used exclusively to refer to patients with no symptoms AND no history of any colon-related problems. If a patient is currently asymptomatic but has a history of polyps or other gastrointestinal disease, their procedure is termed a “surveillance” colonoscopy and needs a different billing code. The American Society of Colon and Rectal Surgeons issues recommended schedules for such surveillance, and these schedules usually suggest a procedure every two to five years. Surveillance colonoscopies are covered by Medicare in the same manner as diagnostic colonoscopies, which means the patient is responsible for a co-pay of 20 percent of procedure costs.

When Does a Colonoscopy Become “Diagnostic?”

If a patient or the doctor suspects a problem, the procedure is clearly diagnostic from the outset, and the billing category can be properly entered when the appointment is made. However, if a physician is conducting a routine screening colonoscopy on an asymptomatic patient with no history and finds a polyp, the reimbursement and billing category is suddenly changed. This creates problems for the billing personnel, who have to go back in and add a modification code for the appointment and then bill the patient for a co-pay. Meanwhile, patients may have been counting on the free routine screening that they believe they were promised, and may become angry and resistant to paying. All too often, the pace of a busy office means that the provider just accepts an 80 percent reimbursement at Medicare’s already low rates without even fully realizing the discrepancy.

Good Practice Management Can Avoid the Problem

Once physicians and billing staff become aware of this issue, they can educate patients. When making an appointment, patients should be asked about what led them to make this appointment. Do they have a history of problems? Did a doctor recommend that they have colonoscopies more often than every 10 years? Are they simply trying to be proactive because of the encouragement of the ACA? Once the reasons for the colonoscopy are clear, then the provider can explain the complexities of the law as it currently exists, and express a sentiment of being on the same team as the patient. This, in turn, will help patients understand if they need to remit a 20 percent co-pay, and the practice will benefit from a much stronger financial position.


abeo Management Corporation (abeo) serves as a leading source of revenue cycle management and practice management with a specialization in anesthesia. The company leverages its people, processes, and software to serve independent practices, surgery centers, hospitals and healthcare systems with a scope of services that include billing, coding, transcription, practice management, and business consulting.

Join Our Newsletter