# Cologuard (+) Indication for Colonoscopy



## aguerrero14

Good Morning All!
I am curious if anyone has recently had to code an office visit or colonoscopy for a positive Cologuard Test.  I am the biller and coder in a Gastroenterology office.  

Scenario:

Patient sees Primary MD, and is given the Cologuard Test Kit, Test is positive and Patient is referred to our office for a Colonoscopy. Patient's 2 previous colonoscopies were normal. Patient is referred to our office as the Primary has deferred the decision to our Doc. If a patient has a positive Test result, wouldn't the colonoscopy be considered diagnostic? What if the patient had never had a colonoscopy before? How do we justify a screening when a test has shown a possibility of polyp or cancer?

 I have not been able to find any documentation supporting a screening code.  If the patient is 50 and due for a screening colonoscopy anyhow, why would the Primary Physician order a cologuard?  The Patient should just be referred to Gastroenterology for 1st Screening in order for the patient to receive insurance benefits under their preventative care.

I have been battling with patients about their screening benefits because they think everything is at no cost to them even if polyps are removed.  Some insurance plans (UHC, specifically) do not recognize screening or high risk screening IF a polyp was removed.  Now, add this cologuard test into the mix and I'm feeling like I will really be at odds with my patients and doctors, since they have made the decision for a screening test. Will my office have to "warn every patient with a + Cologuard that the subsequent Colonoscopy will be processed as a diagnostic exam, even if the patient was due for a screening, high risk screening, or "surveillance" Colonoscopy?

Sorry for the long post. I want to be sure that my explanation is clear.

Thank you in advance for your opinions and suggestions!!


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## elaine.pulsepoint@icloud.com

Once a screening of any kind detects something, the patient is no longer in a screening status.  When the primary care's office ordered the Cologuard, they billed the preventive and they used up that 1 screening service per reporting period benefit (they reported the Z12.11).  

Cologuard is expensive and if the results detect a reason to have further testing, any subsequent test/service is now diagnostic (just like a fecal blood occult positive).   R19.5 for other fecal abnormalities or Z15.09 genetic susceptibility to other malignant neoplasm are options for billing the colonoscopy.

The PCP may or may not explain this to the patient, so it's best that when a patient contacts your office with a +cologuard result, you have a policy in place that explains to them they are now a symptomatic patient and copays/deductibles/coinsurance will apply if required by their insurance policy.

You can provide the patient with the CPT and DX codes and advise them to contact their insurance company to review their benefits.  It's often easier for a patient to hear their financial obligation from the payer than from their provider.


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## aguerrero14

Thank you!!!


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## kellibeasley

*LCD check*

Just be sure to check your Local Coverage Determinations for the colonoscopy codes.  Z15.09 may not be a payable dx for 45378.


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