Gastroenterology Coding Alert

Question: We have a patient who is not due for a screening colonoscopy for another four years, but their pulmonologist is referring them for an earlier screening because they recently had lung, and currently has endometrial, cancer. Is this considered high risk and therefore covered? Should I submit the claim like a standard screening colonoscopy?

AAPC Forum Participant

Answer: In short, you’ll want to check with the payer. Some payers cover early screenings due to a patient being considered high risk, but the definitions for what qualifies as high risk vary. For example, Medicare considers an individual at high risk of developing colon cancer if they have one or more of the following characteristics:

• A close relative (sibling, parent, or child) who has had a colorectal cancer or an adenomatous polyp
• A family history of familial adenomatous polyposis
• A family history of hereditary nonpolyposis colorectal cancer
• A personal history of adenomatous polyps
• A personal history of colorectal cancer
• Inflammatory bowel disease, including Crohn’s disease and ulcerative colitis

The patient you describe does not look to be a candidate for a covered screening according to Medicare, but other payers could have different criteria. Therefore, the payer policy (and of course, your provider’s thorough documentation) will dictate whether you bill this as a screening or a diagnostic colonoscopy. Consider getting an advanced beneficiary notice (ABN) and explain to the patient the procedure might result in their financial responsibility. Also explain the possibility of appeal. A stipulation of circumstances, along with a referral by a different specialist, might be enough to overturn the denial.