E/M service prior to a screening colonoscopy

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

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