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Colonoscopy Billing Reminder- Preventive vs. Diagnostic

The Affordable Care Act (ACA or health care reform law) requires nongrandfathered health plans to cover certain preventive care and screenings without member cost sharing when provided in-network. Colorectal cancer screenings are a covered preventive care service under these guidelines.  
Since colonoscopies are rendered for both screening and diagnostic purposes, it is very important for providers to use appropriate ICD-9 diagnosis coding guidelines when reporting colonoscopies. When inappropriate ICD-9 diagnosis codes are submitted on claims, it can result in incorrect provider payment and/or incorrect member cost sharing.  
To reduce claim adjustments and the possible need for corresponding refunds to members, we recommend the following approach when coding a colonoscopy claim.  
When an individual presents solely for the purpose of a screening exam, without any signs or symptoms of a disease, then the procedure should be considered a screening. [The appropriate use of diagnosis codes and screening procedure codes is valuable in promoting appropriate adjudication of the claim.
When an individual presents for a screening exam (without signs or symptoms), if an issue is encountered during that preventive exam, that would warrant the use of the PT modifier. The procedure and diagnosis codes that would typically be used in such an instance may not clearly demonstrate that the service began as a screening procedure but had to be converted to a diagnostic procedure due to a pathologic finding (e.g. polyp, tumor, bleeding) encountered during that preventive exam.
When an individual presents with signs or symptoms and the exam is performed to rule out or confirm a suspected diagnosis, the encounter should be considered a diagnostic exam, not a screening exam. In this case, the modifier PT should not be used and the sign or symptom should be used to explain the reason for the test.
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