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Archive March 2018 XIX, No. 3

Coding & Billing: Avoid Common Colonoscopy Billing Blunders

Simple steps to head off confusion about patients' insurance coverage.

Stephanie Ellis

Stephanie Ellis, RN, CPC


NO SURPRISES To be sure you don't disappoint patients when you ask for a co-pay or a deductible, help them understand their insurance coverage before the colonoscopy.

As if colonoscopy patients don't have enough to worry about, their insurance coverage can be as hard to stomach as a laxative prep. But just as a good cleansing prep is a key part of a colonoscopy, so, too, is a thorough understanding of your patient's colonoscopy benefits, which can vary widely from one insurance plan to the next depending on the procedure you perform. Patients who think their insurance covers everything will surely be disappointed when you ask for a co-pay or a deductible when what was scheduled as a "screening" or "surveillance" colonoscopy turned into a biopsy or a polypectomy procedure. Here are 2 tips to avoid financial headaches with your GI patients.

1 Know the specific type of colonoscopy. The GI physician's scheduler might be the unwitting source of the confusion. If she calls in every procedure simply as a "colonoscopy," ask that she specify what type of procedure is going to be performed. Why is the patient having the procedure done? Is it for screening purposes (for patients with no symptoms and no history), surveillance purposes (for patients who have a personal or family history, placing them at high risk) or is it a diagnostic colonoscopy for symptoms?

Why is this important to know? Because the benefits for the different types of procedures usually vary — and this could determine a patient's out-of-pocket obligation. Case in point: Let's say the patient is covered at 100% for a "screening" or "surveillance" procedure. But he would owe his regular deductible and possibly a co-pay if the surgeon does a biopsy or polypectomy procedure. Not only should you thoroughly understand the patient's benefits, but you should also explain them in detail to the patient before the procedure. This way, it's not a surprise when you ask for payment. Stress to the patient that you won't know if he'll owe anything out-of-pocket until after the colonoscopy. Remember, if you don't explain their benefits to them on the front end, patients could easily think that you incorrectly billed their procedure or are mistakenly charging them — and maybe even that you committed fraud.

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