Getting Paid When Screening Colonoscopies Turn Into Diagnostic Procedures

After weeks of confusion and rejected claims, carriers should be properly reimbursing GI facilities that use the new PT modifier to bill for Medicare-covered colonoscopies that start out as screening procedures but end up as diagnostic procedures due to the finding of a polyp or some other clinical indication, says the Ambulatory Surgery Center Association.

The problem stemmed from a healthcare reform initiative that lets Medicare beneficiaries receive such preventive care as a screening colonoscopy for colorectal cancer with no money out of pocket, says Marie Edler, ASCA's former director of state and reimbursement policy. When a Medicare beneficiary presents for a covered screening colonoscopy, Medicare will pay the full provider and facility fee. The patient, meanwhile, isn't responsible for a deductible or a copay. As is sometimes the case, however, a clinical finding can change a screening to an actual diagnostic procedure. Medicare introduced the PT modifier, effective Jan. 1, 2011, and applicable to the physician and the facility, to address such scenarios, says Ms. Edler.

"If a patient was scheduled for a Medicare covered screening colonoscopy but during the screening itself the procedure changed to a diagnostic colonoscopy, then Medicare would still honor the waiver of the patient's deductible - though not the copay - in response to the screening benefit the beneficiary had believed they would be entitled to," says Ms. Edler.

Things didn't go as planned, however. ASCs across the country reported that regional carriers were rejecting claims billed with the PT modifier with a variety of denial explanations. Medicare told ASCA last week that it was issuing private clarifications and instructions directly to the carriers to correct the claims processing errors, says Ms. Edler.

Dan O'Connor