Insurance Payment (US) for Colonoscopies

I recently had an unwelcome surprise when I received my "Statement of Benefits" from my insurance company after my 5 yr Colonoscopy (I am an ex Colon cancer patient). While the insurance plan covers "Screening" Colonoscopies in their entirety, they dealt with mine as "continuing treatment" with a much lower coverage level (i.e. they paid less and charged the balance to my deductible). What I learned was that this charge was because the doctor didn't enter the code for screening, but the one for followup exam.

I do not know how common this practice is, but it's always better to avoid surprises.

That sucks. Thanks for the heads up. I'll be sure to check coverage before scheduling my next.

The coding is essentially correct; the code supports the diagnosis and vice versa. However, coders have a great deal of leeway (within certain parameters) in how they code. I suspect that because you have a previous history of colorectal cancer, your colonoscopies from this point forward will be termed as follow-up procedures, and not as screening.

Ladydoc,

If you've had non-cancerous polyps removed during an earlier colonoscopy is the next colonoscopy, 3 or 4 years later, considered treatment or screening?

If I remember correctly, if the polyps were read by a pathologist as benign hyperplasia, or something in that class, further colonoscopies would be classed as screening. They are not follow-ups until cancer has been diagnosed and treated. Best thing to do if you have questions is to talk to a biller/coder at your doctor's office.

I've appealed the Ins Co's decision based on my Oncologist's discharging me from any further care and his statement that I'm cured of Colon Cancer. He also said that any appearance of Colon cancer would be a new instance of the disease.

Wish me luck.

Very good point tuber! I wonder if somewhere on a billing form there isn't a "V" code followed by two digits. That's an indicator of "previous history of" or "status post". Those tend to follow you around forever and an insurance company can make a case for lesser payments based on that.

Good luck doing battle with the dragon!