E/M service prior to a screening colonoscopy

December 29th, 2015 - Codapedia Editor
Categories:   Bundling   Colonoscopy   Medicare   Screening  

CMS does not pay for an Evaluation and Management service prior to a screening colonoscopy.  If a patient calls or is sent from another physician to schedule a screening colonoscopy, do not bill any type of E/M service prior to the procedure.  Some commercial carriers also follow this policy.

If the patient needs a diagnostic colonoscopy, for a symptom or disease, the physician may see the patient and report a medically necessary E/M service.

CMS clarified this in 2002.  The American Gastroentrology Society had an article posted on their website that describes this, however they have removed the link to the service. Here is what the article said:

Section 1862(a)(1)(A) of the Social Security Act states "that no payment may be made for items or services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. In addition, section 1862(a)(7) prohibits payment for routine physical checkups. Taken together, these sections prohibit payment for routine screening services, i.e. those services furnished in the absence of signs, symptoms, complaints, or personal history of disease or injury. The only exceptions are screening services that are specifically authorized by statute, such as colorectal cancer screening tests covered under 1861(s)(2)(R)? While the law specifically provides for a screening colonoscopy, it does not also specifically provide for a separate screening visit prior to the procedure?.Thus, a pre-procedure visit performed on an asymptomatic patient prior to a screening colonoscopy is not covered under current law. We would note that while we do not currently make a separate payment for these visits, fee schedule payment amounts for all procedures, including colonoscopy, contain payment for the usual pre-procedure work associated with the procedure.

Unless a Preventive Medicine Service code is used, billing for the visit preceding a screening colonoscopy, as either a Consultation or New or Established Patient Visit, for a patient with no symptoms, would constitute a False Claim. The AGA continues to seek legislative remedies to address this issue. Unless and until Congress passes a law making the pre-procedure visit a covered service, physicians and their support staff should be careful not to bill the visit incorrectly.

A CIGNA LCD and a letter from Rhode Island's carrier are attached as resources to this article.  The CIGNA LCD says this, very clearly:

A provider preparing to perform a screening colonoscopy cannot also bill for a pre-procedure visit to determine the suitability of the patient for the colonoscopy. These E/M services, to include consultations, are not separately payable. While the law specifically provides for a screening colonoscopy, it does not also specifically provide for a separate screening visit prior to the procedure. Although no separate payment can be made for these visits currently, the fee schedule payment for all procedures, including colonoscopy, contains payment for the usual pre-procedure work associated with it. This reflects the principle that each procedure has an evaluative component.
 

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association