E/M service prior to a screening colonoscopy

December 29th, 2015 - Codapedia Editor
Categories:   Bundling   Colonoscopy   Medicare   Screening  
0 Votes - Sign in to vote or comment.

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)

​​Polysomnography Services Under OIG Scrutiny
September 2nd, 2021 - Raquel Shumway
The OIG conducted a study dated June 2019 wherein they indicated that there were approximately $269 million in overpayments for polysomnography services for the period of 2014 through 2015. According to the OIG “These errors occurred because the CMS oversight of polysomnography services was insufficient to ensure that providers complied with Medicare requirements and to prevent payment of claims that didn’t meet those requirements.” So what are those requirements?
Medicare Advantage - The Fastest Growing Government-Funded Program Undergoing Multiple Fraud Investigations
August 16th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Medicare Advantage is the fastest growing form of government-funded healthcare and the rate of fraud within this segment has come under increased scrutiny. Funding is determined by the health status of each beneficiary; therefore, accurate coding based on detailed documentation makes the medical record vital to the process because some ...
Billing Dental Implants under Medical Coverage
August 12th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Implants can be costly to the patient and the provider, and it is crucial to understand how to bill a patient’s medical insurance to ensure there is adequate coverage for the best treatment. Implants are commonly billed in a dental office under a patient’s medical benefits.    Implants could be considered ...
New Codes for COVID Booster Vaccine & Monoclonal Antibody Products
August 10th, 2021 - Wyn Staheli, Director of Research
New codes have been announced for the COVID-19 booster vaccine, Novavax vaccine, and monoclonal antibody treatment.
Medicare's ABN Booklet Revised
July 29th, 2021 - Wyn Staheli, Director of Research
The “Medicare Advance Written Notices of Non-coverage” booklet, published by CMS’s Medicare Learning Network, was updated. This article discusses the changes to this booklet regarding the use of the ABN.
Chronic Pain Coding Today & in the Future
July 19th, 2021 - Wyn Staheli, Director of Research
Properly documenting and coding chronic pain can be challenging. As is commonly the case with many conditions, over the years, there has been a shift in the identification of different types of pain, including chronic pain. Understanding where we are now and where we are going will help your organization prepare for the future by changing documentation patterns now.
How Does Global and Professional Direct Contracting (GPDC) Affect Risk Adjustment?
July 15th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
CMS recently announced the 53 Direct Contracting Entities (DCEs) that will be participating in the April 1, 2021 through December 31, 2021 Global and Professional Direct Contracting (GPDC) Model. Among those participating is Clover Health Partners, who runs an in-home primary care program that has the potential to help Medicare ...



Home About Contact Terms Privacy

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

Copyright © 2000-2021 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association