Dr. Michael W. Goodman & Dr. Matthew E. Bagamery

Understanding Colonoscopy Categories & Insurance Coverage

What You Need to Know Under the Affordable Health Care Act

What Michael W. Goodman, MD, PC wants you to know if you are about to have a Colonoscopy.

The Affordable Care Act “Obamacare,” passed in March 2010, allows for several preventive services, including colorectal cancer a screening, to be covered at no cost to the patient. Colonoscopy is one form of colorectal cancer screening.

Colonoscopy patients fall into 3 different categories and strict coding guidelines are used to determine under which category (screening vs. diagnostic) you may fall. These guidelines may exclude those patients with a history of gastrointestinal issues from taking advantage of the procedure at no cost. In cases like these, patients may be required to pay deductibles and co-pays.

Although your primary care physician may refer you for a “screening colonoscopy”, you may not qualify for the “preventive colonoscopy screening” category.

Colonoscopy Categories

  • Diagnostic/Therapeutic Colonoscopy – Patient has gastrointestinal symptoms, colon polyps, or gastrointestinal disease requiring evaluation or treatment by colonoscopy (CPT code: 45380 – See # 1 below).
  • Surveillance/High Risk Colonoscopy Screening – Patient is asymptomatic (no present gastrointestinal symptoms) and has a personal history of Crohn’s Disease, Ulcerative Colitis, or a personal or direct relative with colon polyps, and/or colon cancer. Patients in this category are required to undergo colonoscopy surveillance at shortened intervals (usually 2-5 years) and depending on your insurance carrier, this category may be reimbursed as if you were having a diagnostic colonoscopy (CPT code: 45378/G0105 – See #2 below).
  • Preventive/Average Risk Colonoscopy Screening (Included as part of the Affordable Care Act) – Patient is asymptomatic (no present gastrointestinal symptoms), is 50 years old or older and has no personal history of gastrointestinal disease, colon polyps, and/or cancer. Patients in this category have not undergone a colonoscopy within the last 10 years (CPT code: 45378/G0121– See # 3 below).

To determine the category of your colonoscopy and approximate insurance benefits, please follow the steps below:

  1. Obtain the preoperative CPT and diagnosis codes from the medical assistant.
  2. Call your insurance carrier’s customer service line and verify your specific benefits and coverage by asking the following questions:
  3. How will my coverage reimburse for the following CPT codes and associated diagnoses?

    1. CPT Code: 45380 Diagnosis(es)___________________________________________

    2. CPT Code 45378/G0105 Diagnosis(es)___________________________________________

    3. CPT Code 45378/G0121 Diagnosis(es)___________________________________________
  4. Will the claim be processed as:

    Preventive (Routine/Screening) or

    Surveillance or

    Diagnostic?

  5. Will this colonoscopy be paid by the insurance company at 100% as defined by the Affordable Care Act?

    Yes

    No

  6. If my procedure is a preventive (screening) procedure, does my insurance company have age, frequency, or personal/family history limitations for my colonoscopy (e.g. one every ten years over age 50, one every two years for personal history of polyps beginning at age 45, etc.)?

    Yes (if YES, list limitations:_____________________________)

    No

  7. If the physician removes a polyp, will this change my out of pocket responsibility? (A biopsy or polyp removal may change a screening benefit to a medical benefit, which means more out of pocket expenses. Carriers vary on this policy.)

    Yes

    No

Obtain the following information from your insurance representative:

After speaking with your insurance representative, feel free to contact Michael W. Goodman, MD, PC’s billing office (423 265-0398) with any questions or concerns, or if necessary, to make payment arrangements.

Frequently Asked Questions

1. How many charges can I expect to receive?

You will receive one charge from the doctor, one from Anesthesia and a facility charge if your procedure was done at a hospital instead of our Endoscopy Suite. Additionally, if clinical findings necessitate a biopsy, then you would receive a charge for Pathology services. You could receive as many as 4 different bills for your colonoscopy.

2. Can the physician change, add, or delete my diagnosis so that my procedure can be considered a preventative screening?

NO. The patient encounter is documented as a medical record from information you have provided, as well as evaluation and assessment by the provider. It is a binding legal document that cannot be changed to facilitate better insurance coverage.

However, if a patient notices an error in the medical record (e.g. date of birth, medication dosage, history notation, etc), he/she may request a correction/amendment by contacting the provider’s office immediately.

3. What if my insurance company tells me that Michael W. Goodman, MD, PC can change, add or delete a CPT or Diagnosis code?

If you are given this information, please document the date of the call, name and phone number of the insurance representative to whom you spoke. Then contact our billing office at 423 265-0398 and we will facilitate a coding review of your medical record.

4. Is an Upper Endoscopy (EGD) part of the Affordable Care Act?

NO and all patients will be responsible for their deductible, co-insurance and co-pays as detailed in their health insurance policy.

Erlanger Medical Mall
979 East Third Street
Suite C-0630
Chattanooga, TN 37403
423.267.5677