Colonoscopy patients fall into 3 different categories and strict coding guidelines are used to determine under which category you may fall. These guidelines may preclude your procedure being covered at 100% by your insurance carrier even though your primary care physician may have referred you for a “screening” colonoscopy. A personal or family history may be the basis for your procedure to be considered either a diagnostic or surveillance colonoscopy as determined by each individual health insurance carrier policy.
1. Diagnostic / Therapeutic Colonoscopy – Patient has gastrointestinal symptoms (ex. blood in stool, changes in bowel habits, hemorrhoids), colon polyps, or gastrointestinal disease requiring evaluation or treatment by colonoscopy.
2. Surveillance / High Risk Colonoscopy Screening – Patient is asymptomatic (no present gastrointestinal symptoms) and has a personal history of Crohn’s Disease, Ulcerative Colitis, or a personal or direct relative with colon polyps, and/or colon cancer. Patients in this category are required to undergo colonoscopy surveillance at shortened intervals (usually every 2 – 5 years) and depending on your insurance carrier, this category may be reimbursed as if you were having a diagnostic colonoscopy.
3. Preventive / Average Risk Colonoscopy Screening (Included as part of the Affordable Care Act) – Patient is asymptomatic (no present gastrointestinal symptoms), is 50 years old or older and has no personal history of gastrointestinal disease, colon polyps, and/or cancer. Patients in this category have not undergone a colonoscopy within the last 10 years.