Gastroenterology Coding Alert

Question: Of late, we have been getting several calls from our patients saying that their insurance is not covering office visits prior to colonoscopy procedures. Their contention is that the office visit is included as part of the procedure. These are not routine colon pre visits. We have been informing that these procedures do not have global days and we are reporting these procedures as is specified in AMA guidelines. But when insurance companies are saying that we have been billing wrong, it is hard to convince them otherwise. Please suggest apt guidelines to help us in situations like this so that our claims do not get rejected by insurance companies and patients get paid for these procedures.

Kentucky Subscriber

Answer: If the office visit was for a screening colonoscopy, then you cannot bill for the office visit as this visit becomes part of the screening procedure. But if your patient presents to your gastroenterologist with signs and symptoms that your gastroenterologist had to evaluate through a thorough history and examination which he then followed up with a colonoscopy, then this procedure is diagnostic in nature. The office visit can be separately billable in such a scenario.

One way to ensure that your claims do not get rejected is to provide adequate documentation to make it clear to the insurance payers that this procedure is not routine screening and has been conducted to evaluate the patient's signs and symptoms.

The dx codes for the office visit can include the signs and symptoms that the patient was experiencing to support the visit code that you are billing. The procedure code can include the findings that your gastroenterologist observed during the colonoscopy. If there were no significant findings during the colonoscopy, you can still provide the documentation stating that the patient was evaluated for diagnosing signs and symptoms during the initial visit eliminating the possibility that the patient underwent colonoscopy as part of a routine screening procedure. This will ensure that you are communicating to the insurance payer that the procedure was not a routine screening but a diagnostic procedure that needed management with colonoscopy.