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Second opinion needed for this scenerio

Susan Posted Thu 26th of January, 2017 08:55:41 AM
In 2014 a 61 year old patient, with BCBS, had a diagnostic colonoscopy for change in bowel habits, constipation. The results were negative for any polyps or inflammation. Now the PCP has sent her for a screening colonoscopy, patient now has Medicare. Scheduler was told could not schedule a screening because she had already had a colonoscopy but that was not a screening. I said yes you can schedule her with a screening colonoscopy because she has never had one and presents with no problems. I believe that I am correct in stating that yes she can have a screening colonoscopy. Please advise.
SuperCoder Answered Fri 27th of January, 2017 02:21:04 AM

Greetings from!


As per CMS, For beneficiaries 50 and older not considered to be at high risk for developing colorectal cancer, Medicare covers one screening colonoscopy every 10 years.


For beneficiaries considered to be at high risk for developing colorectal cancer, Medicare covers one screening colonoscopy every 2 years, regardless of age.


If the patient was a high risk and now presents without any signs or symptoms, you may report this as a screening colonoscopy. But if the patient was not a high risk, then you cannot report second screening colonoscopy before 10 years.


Please feel free to write if you have any concern or questions.



Susan Posted Mon 30th of January, 2017 08:46:15 AM
I am a bit confused, still. The previous colonoscopy was due to patient having symptoms, so this was diagnostic not a screening. The results were negative for any polyps or UC, so patient is at low risk. My thought process is that she has never had a screening before so what if in the mean time she has developed polyps and your saying she will need to wait 10 years before she can have her initial screening? What am I missing here?
SuperCoder Answered Tue 31st of January, 2017 01:33:13 AM


If you are not sure whether the initial screening has been performed or not and the patient at this time is asymptomatic, you may try billing for Screening colonoscopy with modifier 33. If the insurance denies this claim, please call them up and ask the reason of denial and then bill accordingly.


Susan Posted Tue 31st of January, 2017 08:34:34 AM
This patient has never had a screening before just the diagnostic. That is why I am so inclined to believe that she is eligible for her first initial screening. Thank you for your feed back.
SuperCoder Answered Wed 01st of February, 2017 01:48:05 AM


Please bill Screening at this time. The claim should get passed. If not, please let us know.


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