What You Need to Know Under the Affordable Health Care Act

The Affordable Care Act “Obamacare,” passed in March 2010, allows for several preventive services, including colorectal cancer 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).
  • 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).
  • 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).

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If you need additional information, please call us at (423) 267-5677, or send an e-mail to info@goodman-gi.com.

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