Medical billing question re routine screening

[Hayden]

I have a HDHP. My understanding is that the insurance company pays the cost of routine screening (it is not charged against my deductible).

I have a pain in my side. My PCP suggested that when i have a colonoscopy the doctor would look around for a possible cause. I am due for a routine colonoscopy at this time.

So, if i go to a gastroenterologist and ask for a routine screening colonoscopy i will not be charged. But, if i tell him i have a pain in the side and want him to look around while doing the colonoscopy, i will be charged?

Am i correctly understanding the rules?

[Rupert]

If it works anything like mammograms, then, yes, you are correct. Actually having a medical problem changes the nature of the test from screening to diagnostic, in which case normal copays, deductibles, and co-insurance for diagnostic testing would apply. Talk to the gastrodoc beforehand though, as he/she might be able to rule out any problem before the colonoscopy and code the procedure as screening.

[mc2]

I understand your desire to not spend money, but you are depriving yourself and the Dr. from providing you with the care you need by withholding symptoms. Not all problems show up on diagnostic tests, and not all findings have outright symptoms. Just tell the truth and don't play games.

[ks289]

If you are going for an office visit for evaluation for (?abdominal) pain, then this is billed as a consultation or new patient office visit for the pain. A pre colonoscopy office visit cannot typically be included under screening, which is why many colonoscopies are booked directly without an office visit.

The colonoscopy procedure (if indicated for screening) can probably be billed under screening if the main intent is screening (no significant symptoms) and there happens to be a secondary/incidental related symptom (minor rectal bleeding, chronic diarrhea, abdominal pain, etc). However, depending on insurance it could still be considered diagnostic/therapeutic if polyps are removed or biopsies are obtained.

That being said, it is quite possible that other testing (such as a CT scan) could be warranted to evaluate the pain before performing a colonoscopy.

Good luck.

[Mayday]

If you're over 50 the colonoscopy should be covered in full under preventive care. However, if your visit is due to a pain then they are preforming the colonoscopy to look for something and it's no longer a preventive procedure. It would likely be coded as diagnostic and depending on your plan design and where you are at with your annual deductible you may be on the hook for the full cost of the procedure. (You would still get your insurance carriers negotiated discounts)

[Hayden]

Thank you for the responses. It sounds like if I want to pursue this, i need to be prepared to pay the full cost of the colonoscopy. My next step will be to find out how much that will be.

[mhalley]

Certainly a colonoscopy is WAY down on the list of diagnostic procedures to diagnose abdominal pain. Certainly worthwhile to have it done for screening, but unless there are other symptoms (bleeding, diarrhea) it will probably not add to figuring out the cause of the pain.
As to the cost, that can vary greatly. Your insurance co. web page may have a page about costs of procedures you could look at.

[Hayden]

Certainly a colonoscopy is WAY down on the list of diagnostic procedures to diagnose abdominal pain. Certainly worthwhile to have it done for screening, but unless there are other symptoms (bleeding, diarrhea) it will probably not add to figuring out the cause of the pain.
As to the cost, that can vary greatly. Your insurance co. web page may have a page about costs of procedures you could look at.

Thanks for the tip! Premera does have a web page to provide approximate costs of procedures. I never knew that!

[LWalker]

If you are due for a routine colonoscopy, schedule it. Schedule it as a routine screening procedure. The screening status is based on the original order from your PCP. Make sure the PCP orders it as a screen, not as a diagnostic.

The remark from your PCP is peculiar. It does not really make any sense. He or she needs to give you a much clearer answer about what the possibilities are, whether you should be concerned about your abdominal pain, whether you should have tests to figure it out, and whether you should try anything such as diet modifications or medicine.

When you go for the routine screening colonoscopy that you do need, you will be speaking to the person who performs the procedure beforehand. This will be on that same day, after you check in for the procedure. If you are concerned about your abdominal pain you should absolutely talk about your concern at that point, and ask whether it is likely that the colonoscopy can help figure it out.

This should in no way change either the procedure they do or the status as a screening procedure (or the billing or insurance status.)

Colonoscopy is done in a standardized way and won't be much different if you give the person, probably a gastroenterologist, information about symptoms, but you should definitely supply the information.

[woof755]

I agree with these suggestions. Colonoscopy infrequently identifies the cause of abd pain that is not associated with other more worrisome symptoms. I would plan on having a screening colonoscopy, with my GI doc knowing that there is a discomfort that has been noted that he or she can keep in back of mind as the procedure goes along.

But anything seen during a colonoscopy is going to be seen whether you are having pain or not. It's the colon--there isn't anywhere else to "take a look around" when we're in there. "Taking a [really, really good] look around" is literally the purpose of the procedure.

[Hayden]

If you are due for a routine colonoscopy, schedule it. Schedule it as a routine screening procedure. The screening status is based on the original order from your PCP. Make sure the PCP orders it as a screen, not as a diagnostic.

The remark from your PCP is peculiar. It does not really make any sense. He or she needs to give you a much clearer answer about what the possibilities are, whether you should be concerned about your abdominal pain, whether you should have tests to figure it out, and whether you should try anything such as diet modifications or medicine.

When you go for the routine screening colonoscopy that you do need, you will be speaking to the person who performs the procedure beforehand. This will be on that same day, after you check in for the procedure. If you are concerned about your abdominal pain you should absolutely talk about your concern at that point, and ask whether it is likely that the colonoscopy can help figure it out.

This should in no way change either the procedure they do or the status as a screening procedure (or the billing or insurance status.)

Colonoscopy is done in a standardized way and won't be much different if you give the person, probably a gastroenterologist, information about symptoms, but you should definitely supply the information.

Thanks. I appreciate the detailed response.

[Hayden]

I agree with these suggestions. Colonoscopy infrequently identifies the cause of abd pain that is not associated with other more worrisome symptoms. I would plan on having a screening colonoscopy, with my GI doc knowing that there is a discomfort that has been noted that he or she can keep in back of mind as the procedure goes along.

But anything seen during a colonoscopy is going to be seen whether you are having pain or not. It's the colon--there isn't anywhere else to "take a look around" when we're in there. "Taking a [really, really good] look around" is literally the purpose of the procedure.

This is good to know. Thanks!