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Regional Digestive ConsultantsDr. Behara, MD, AGAFDr. Shailaja BeharaRDCRegional Digestive Consultants



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Understanding Colonoscopies and Insurance Coverage

The Affordable Care Act, passed in March 2010, allows for several preventive services, such as colonoscopies, to be covered at no cost to patients. Preventative coverage with no cost-share only applies to patients with a non-grandfathered health plan. However, strict guidelines are used to define the type of colonoscopies our physicians perform: preventive (screening), diagnostic, or surveillance.

Colonoscopy: Screening or Diagnostic?

Please read through this Q&A to understand your colonoscopy before scheduling an appointment with RDC. Please let us know if you have any questions!

Screening or Diagnostic – What’s the difference?
A screening colonoscopy is a preventative procedure meant to evaluate the health of a patient’s colon. Screenings are covered by Medicare and typically covered by insurance after the age of 50 as a preventative measure against colon cancer.

Colonoscopy Categories:

Preventative Screening Colonoscopy
You aren’t showing any signs of gastrointestinal symptoms (past or present), over the age of 50, have no family history of GI disease, colon polyps, and/or colon cancer. The definition of a ‘Screening Colonoscopy’ per CMS guidelines is as follows. “A colonoscopy being performed on a patient who does not have any signs or symptoms in the lower GI anatomy and has not had a colonoscopy within 10 years PRIOR to the scheduled test.”

Surveillance/High Risk Screening Colonoscopy
You aren’t showing any signs of gastrointestinal symptoms (past or present) but do have a family history of GI disease, colon polyps, and/or colon cancer.

Diagnostic/Therapeutic Colonoscopy
You have had past and/or present gastrointestinal symptoms, such as a change in bowel habits, diarrhea, constipation, rectal bleeding, anemia, etc. prior to the procedure, and noted as a symptom by the physician in your medical record, may change your benefit from a screening to a diagnostic Colonoscopy.

Please note: If you’ve had a colonoscopy within the last 10 years and the result indicated you had colon polyps, you are NOT eligible for a Preventative Screening Benefit. You have a prior history of colon polyps, thus, your colonoscopy is now a ‘Surveillance of the Colon’ and is considered a diagnostic and not preventative procedure.

Please note: If you are under the age of 50 and being seen for a screening colonoscopy, you may not be eligible for a Preventative Screening Benefit. It is your responsibility to know your insurance policy and the services covered by your plan. Please contact your insurance company with benefit questions prior to your procedure.

Please be advised that if during the procedure your doctor finds a polyp or tissue that must be removed for pathological testing, the fees for pathology services are NOT covered by the Preventative Screening Benefit and will be applied to your deductible or coinsurance.

Can a screening turn into a diagnostic colonoscopy?

Yes, it is possible. Before your procedure, it is very important that you know your colonoscopy category. If polyps are detected during your screening and results in removal and biopsy, the screening will be classified as a diagnostic colonoscopy. This may change your insurance benefits for the procedure and additional costs may be incurred. Remember that coding of the procedure is also based on the doctor’s evaluation when it comes to your symptoms and insurance coverage. Please be truthful with your doctor when it comes to your GI symptoms and history (past and present) to prevent unexpected code changes and charges.

Can the doctor change my diagnosis code?

No! It is against the law for your doctor to change your code (no matter what your insurance may tell you) and is considered insurance fraud. Your medical record is a binding legal document that cannot be changed to facilitate better insurance coverage. This is why it is important to be truthful and report any symptoms to your doctor, along with understanding what your insurance will cover so that you don’t have any surprises.

Who will bill me?

You may receive bills for separate entities associated with your procedure, besides your doctor. This includes the facility, anesthesia, pathologist, and/or laboratory. We can only provide you with information associated with our fees. It is important that you ask your insurance provider to verify the benefits and costs with these additional entities.

How long does it take to find out my results?

RDC makes it a mission to share your results with you as soon as available. We do not share pathology or imaging with patients nor discuss results over the phone unless approved by the physician. We prefer you to come into the office for a face-to-face discussion of results.

We make every effort to code correctly for your procedure with the right modifiers and diagnoses. The correct coding of a procedure is driven by the physician and your medical history, and is not dictated by your procedure with the right modifiers and diagnoses. The correct coding of a procedure is driven by the physician and your medical history, and is not dictated by your insurance benefits or a particular insurance company.

Please contact our office for further details by calling us at 281-528-1511.


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