What you need to know

The Affordable Care Act passed in 2010 allowed for several preventive services, such as colonoscopies, to be covered at no cost to the patient. However, there are many circumstances that may prevent patients from taking advantage of this provision. There are now strict and changing guidelines on which colonoscopies are defined as a preventive service (screening). These guidelines may exclude many patients with gastrointestinal (GI) histories from taking advantage of the service at no cost. Patients may be required to pay co-pays and deductibles.

Our facility has created this document to sort through some of the confusion and misinformation.

Colonoscopy Categories:

  • Diagnostic/Therapeutic Colonoscopy
    Patient has past and/or present gastrointestinal symptoms, polyps, or GI disease.
  • Surveillance/High Risk Screening Colonoscopy
    Patient has no GI symptoms (past or present), has a personal history of GI disease, colon polyps, and/or cancer. Patients in this category are required to have surveillance colonoscopies at reduced intervals (e.g. every 1-5 years).
  • Preventive/Screening Colonoscopy
    Patient has no GI symptoms (past or present), is over the age of 50, and has no personal or family history of GI disease, colon polyps, and/or cancer. The patient has not undergone a colonoscopy within the last 10 years.

Your primary care physician may refer you for a “screening” colonoscopy; however, you may not qualify for the “screening” category. This is determined in the pre-operative process by the physician performing your procedure. Once you have established your procedure category, you will be able to research your insurance coverage.

Who will bill me?

You may receive bills from multiple separate entities associated with your procedure, such as physician, facility, anesthesia, pathologist, and/or laboratory. Pend Oreille Surgery Center (POSC) can only provide information associated with our own fees.

Can the physician change, add, or delete my diagnosis so that I can be considered a colon screening?

No. The patient encounter is a medical record created from information you have provided as well as an evaluation and assessment from the physician. It is a binding legal document that cannot be altered to facilitate better insurance coverage.

There are strict government and insurance company documentation and coding guidelines preventing a physician from altering a chart or bill for the sole purpose of coverage determination. This is considered insurance fraud and is punishable by law.

What if my insurance company tells me that POSC can change, add, or delete a CPT or diagnosis code?

Often, member service representatives will tell a patient that if the provider would code it with a “screening” diagnosis, it would be covered at 100%. However, further investigation usually reveals that the “screening” diagnosis can only be amended if it applies to the patient. If you are given this information by your insurance company, please document the date, name, and phone number of the insurance representative. Next, contact our billing department, who will audit the billing and investigate the information given. Please be prepared that this often results in the insurance company calling the patient to explain that the member services representative should never suggest a physician change their billing to produce better benefit coverage.