What is a screening service, and how is it different from other medical services?
Medical services have traditionally been classified into one of the following service types based on the reasons for performing the procedure, findings encountered during the procedure, or additional procedures or treatments performed during the procedure.
Screening (preventive)- A procedure or service provided to a patient who does not have symptoms or abnormal findings, or known disease. With respect to colon cancer screening and prevention, it is critical to perform an examination before symptoms arise, when people feel perfectly well. Cancers detected after symptoms develop are often advanced and incurable. Some insurers, and the Affordable Care Act, call screening exams a "preventive service."
Diagnostic - A procedure or service provided to a patient to identify the cause of symptom or abnormal findings, or to evaluate a known disease.
Therapeutic (surgical) - Removal, insertion or repair of pathology found during a screening or diagnostic exam. An examination may begin as screening and change to therapeutic if abnormalities are found.
Also see Colonoscopy FAQs
Why does it matter?
It does not matter with respect to how a colonoscopy is prepared for or performed by the patient, doctor or staff (see Colonoscopy FAQs and Forms Online). It can, however, matter with respect to how a government health plan or private insurance company covers the charges related to the procedure.
Government and private health plans typically provide different levels of benefit based on how a procedure is classified. This classification may determine if a procedure is covered at all, and if covered, it may determine the portion covered by the plan and the beneficiary's deductible and copay responsibility. Historically, plans have differed with respect to how these decisions are made. It has not been unusual for a single insurer to offer many types of plans, each of which provided different levels of coverage for screening procedures. Benefits have also vary based on the type of screening procedure performed. Under the Affordable Care Act (also known as "Obamacare") the manner in which private health plans offer screening benefits is being standardized.
Prior to screening benefits being common, colonoscopy generally would only have been covered if it was performed to evaluate a symptom (such as bleeding) or a known disease process (such as ulcerative colitis needing periodic biopsies to monitor for the development of premalignant changes), and it would not have been a covered benefit if it was performed for screening (in a patient without symptoms) even if performing the screening examination represented appropriate medical care (unless an abnormality was found and reported on the claim form). On denying payment for a screening exam that turned out to be normal the insurer would often explain that it agreed with the medical decision to perform the procedure, but that payment for the procedure was not a contractual benefit of the insured's policy.
Medicare introduced colon cancer screening benefits in 1998, when colonoscopy was added as a screening benefit for "high risk" beneficiaries (see below). In 2001 Medicare added colonoscopy as a benefit for average risk individuals undergoing colon cancer screening.
Since then, most private insurers have also added colonoscopy as a covered colon cancer screening benefit, though the benefit has varied substantially from company to company, and even from group policy to group policy within a single company's plans. This is now undergoing standardization nationally, under the Affordable Care Act, which provides for colorectal cancer screening tests that carry a "grade A" or "grade B" recommendation from the U.S. Preventive Services Task Force.
While in the past many private insurers provided no benefit for screening colonoscopy, covering only diagnostic-therapeutic colonoscopy, many companies now provide a more favorable benefit for screening examinations than for diagnostic-therapeutic exams.
Colorado law - July 1, 2009
As of July 1, 2009 colorectal cancer screening has been a mandated health insurance benefit in Colorado. HB 08-1410 requires small group and individual plans regulated by the state to include coverage for the range of screenings recommended by the U.S. Preventative Services Task Force.
Also see Colonoscopy FAQs
I have Medicare. What is my screening benefit?
Medicare provides for screening colonoscopy every 10 years* for average risk patients and every 2 years for high risk patients. Medicare says you are high risk if you have:
-A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp; or
-A family history of familial adenomatous polyposis; or
-A family history of hereditary non-polyposis colorectal cancer; or
-A personal history of adenomatous polyps; or
-A personal history of colorectal cancer; or
-Inflammatory bowel disease including Crohn's disease, or ulcerative colitis
*screening colonoscopy is not covered if it is performed within 47 months of a previous screening sigmoidoscopy
You should be aware that in most cases your gastroenterologist will advise you not to have a colonoscopy as frequently as every 2 years even if the benefit allows this.
Also see Colonoscopy FAQs
I have private insurance. Where can I learn about my screening benefit?
Contact your insurance company directly, using the telephone number on your insurance identification card. Be ready to provide your plan numbers. You may also be able to obtain information on the company's website. See a current list of our contracted health plans.
Also see Colonoscopy FAQs
How do you report (bill) my exam to my insurance company if it starts as a screening but you find a polyp and remove it? How will that affect my screening benefit?
Medicare has issued an advisory instructing us how to handle this common situation. We will follow the instructions in this Centers for Medicare & Medicaid Services MLN Matters directive when we file a Medicare claim on your behalf. In this case, your deductible payment, which is waived in the case of a screening examination, will not be waived. The statutory language (2007 Medicare Fee Schedule) reads:
..."if during the course of such screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the lesion or growth, payment under this part shall not be made for the screening colonoscopy but shall be made for the procedure classified as a colonoscopy with such biopsy or removal. Based on this statutory language, in such instances the test or procedure is no longer classified as a "screening test.'' Thus, the deductible would not be waived in such situations. "
Medicare's policy regarding this issue changed January 1, 1011. Screening exams are now treated for the purpose of copay obligation as a screening exam even if a polyp is removed.
Private carriers are not subject to Medicare payment rules and typically have established their own preferred definitions, payment policies and reporting instructions. Private health plans are now however subject to regulation under the Affordable Care Act. In February 2013 the Centers for Medicare and Medicaid Services, which has authority over private health plans under the ACA, addressed this issue in a set of FAQs.
FAQs about Affordable Care Act Implementation Part XII
February 20, 2013
Q5: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the USPSTF recommendation, is it permissible for a plan or issuer to impose cost-sharing for the cost of a polyp removal during the colonoscopy?
No. Based on clinical practice and comments received from the American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and the Society for Gastroenterology Nurses and Associates, polyp removal is an integral part of a colonoscopy. Accordingly, the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure. On the other hand, a plan or issuer may impose cost-sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.
If your carrier has specific instructions for us with respect to the coding of our services please communicate this information to our billing offices in advance of your procedure. Our reception staff will confirm your request that we submit your claim as a screening case at the time of your admission to the Southwest Endoscopy Center.
Your carrier can advise you with regard to how they will respond to a claim filed under the scenario posed in this question.
Also see Colonoscopy FAQs
Do I need an office visit in the clinic prior to having a screening colonoscopy?
Maybe. In order to provide you with a safe, effective and comfortable colonoscopy we must have an advanced understanding of your medical history, particularly with regard to any operations you have had, any medical problems that you are being treated for, any drugs and herbal remedies that you are taking, and any allergies or medication intolerances that you may have. We also need to know if you have had any prior difficulty with anesthesia or procedural sedation. Traditionally, this information has been obtained and reviewed in the context of a "preoperative" office visit with the physician who will be performing the procedure, or with a physician assistant or nurse practitioner working with the doctor. These visits entail charges separate from the procedure because the medical reimbursement system does not allow for "bundling" of these fees into a global procedure charge.
Because office visits are time consuming and expensive, Digestive Health developed an open access colonoscopy process which allows many patients referred for screening colonoscopy to avoid coming in to the office for a "pre-op" visit.
In some cases patients may prefer to schedule a preprocedure office visit for an opportunity to learn more about the procedure or to meet the doctor personally prior to making a decision to proceed with scheduling. In some cases we will require an office visit to allow us to become familiar with your medical history. This is more frequently necessary for older patients, who generally have a more complex medical history than younger patients. We may require a preprocedure office visit before a screening colonoscopy for new patients who are 65 years of age or older, and in any other case in which the doctor determines that an office visit is necessary to most effectively obtain the information we need to provide safe and effective sedation and endoscopy care.
In most cases, particularly for relatively young and healthy individuals, our open access interview process can take the place of an office visit*.
*Not all health plans provide for "open access" services.
If I choose to have or am required to have an office visit before a screening colonoscopy, will my insurer pay for it?
If you are privately insured you will need to address this question to your carrier's representative. Private policies differ from one another with respect to how they handle screening benefits. If you have a government plan such as Medicare you may be expected to pay out of pocket for the charges related to an office visit required before a screening colonoscopy. While Medicare provides a screening benefit paying for the colonoscopy itself, it does not provide a benefit to cover the costs of a preprocedure visit. You will need to pay for these charges only if your visit is coded solely as a screening visit (you have no gastrointestinal symptoms).