Colonoscopy [insurance question]

[cvsvm2007]

Hi everyone,

I’m 57 years old and have a colonoscopy scheduled. Although I don’t have any symptoms, my primary care doctor recommended it since my last one was almost six years ago. My gastroenterologist informed me that the procedure won’t be fully covered and will count toward my deductible because I’m on a high-deductible plan. When I reached out to my insurance, they said the gastroenterologist has billed it as a diagnostic procedure (Z86.010) with the colonoscopy code 45380. The doctor explained that because my previous colonoscopy showed possible pre-cancerous polyps, it needs to be coded as diagnostic. However, since I don’t have any symptoms this time, shouldn’t this be considered a routine screening? Have any of you gone through similar situation and is this correct when I read everywhere that pre existing conditions are covered? Also, the doctor told me after 10 years from first scan, they will cover 100%
Thanks!
CVS

[EricJ]

I'm in the exact same situation. I think we're gonna get hosed. I mean we're going to have to cough up a couple thousand dollars. I hope someone can prove me wrong.

[Chardo]

I'm in the exact same situation. I think we're gonna get hosed. I mean we're going to have to cough up a couple thousand dollars. I hope someone can prove me wrong.

Well, you're gonna get hosed for sure. But that has nothing to do with money.

[twh]

I know someone with Ulcerative Colitis. This person has to fight this exact mis-coding every few years. Unless they are removing a polyp, my impression is that this procedure should be covered under preventative care. And, if they go in and find something and do something, then they can re-code it after the fact. This is how it is supposed to work based on what I've heard from this close friend.

[toddthebod]

Hi everyone,

I’m 57 years old and have a colonoscopy scheduled. Although I don’t have any symptoms, my primary care doctor recommended it since my last one was almost six years ago. My gastroenterologist informed me that the procedure won’t be fully covered and will count toward my deductible because I’m on a high-deductible plan. When I reached out to my insurance, they said the gastroenterologist has billed it as a diagnostic procedure (Z86.010) with the colonoscopy code 45380. The doctor explained that because my previous colonoscopy showed possible pre-cancerous polyps, it needs to be coded as diagnostic. However, since I don’t have any symptoms this time, shouldn’t this be considered a routine screening? Have any of you gone through similar situation and is this correct when I read everywhere that pre existing conditions are covered? Also, the doctor told me after 10 years from first scan, they will cover 100%
Thanks!
CVS

Screening colonoscopies are only covered once every 10 years.

I can't tell from your post whether you've had this done or not. How is it you "have a colonoscopy scheduled" yet "the gastroenterologist has billed it"?

If it's already been done, what is your question?

If it hasn't been done, your options are:
1. Pay for it.
2. Switch health plans during open enrollment, then have your colonoscopy next year.
3. Cancel your appointment.
4. Wait until it's been 10 years and find a new doctor who will bill it as a screening colonoscopy.

[Visual Artist]

I’ve had 3 colonoscopies about 5 years apart. The last two were done because I had polyps. They were all benign but a
time span shorter than 10 years is indicated if polyps are found. All procedures were covered without any fees - maybe one had a small co-pay of $60.

Under the ACA bill which made colonoscopies “free” providers are not to submit colonoscopies as diagnostic even if they find polyps if you’re not having symptoms - although they try. Here’s a link from NPR which discuss the issue in more detail with suggested actions:
https://www.npr.org/transcripts/1101861735

[toddthebod]

I’ve had 3 colonoscopies about 5 years apart. The last two were done because I had polyps. They were all benign but a
time span shorter than 10 years is indicated if polyps are found. All procedures were covered without any fees - maybe one had a small co-pay of $60.

Under the ACA bill which made colonoscopies “free” providers are not to submit colonoscopies as diagnostic even if they find polyps if you’re not having symptoms - although they try. Here’s a link from NPR which discuss the issue in more detail with suggested actions:
https://www.npr.org/transcripts/1101861735

If you had a copay, it was not a screening colonoscopy.

[EricJ]

...
If it hasn't been done, your options are:
1. Pay for it.
2. Switch health plans during open enrollment, then have your colonoscopy next year.
3. Cancel your appointment.
4. Wait until it's been 10 years and find a new doctor who will bill it as a screening colonoscopy.

Regarding option 2, I guess you're saying the "once per 10 years" limit is per insurer. I would be pleasantly surprised if true. This might still require certain procedure codes.

[Radical Dreamer]

I'm in the exact same situation. I think we're gonna get hosed.

This is why I wish Bogleheads had upvotes. Consider this one from me.

[Metsfan91]

...I mean we're going to have to cough up a couple thousand dollars. I hope someone can prove me wrong.

If you have insurance, it'll cover it. If you are on high deductible plan, you'll have to pay out of pocket until you max out your deductible. Because insurance covers it, you'll be paying the price set by your insurance and your provider. It is a fraction of total charge - maybe 20/25%. If your insurance doesn't cover it, you won't be eligible for insurer's price, and you'll be stuck with 100% of the charge...This is my experience with some other procedures.

[Zhuang]

I know someone with Ulcerative Colitis. This person has to fight this exact mis-coding every few years. Unless they are removing a polyp, my impression is that this procedure should be covered under preventative care. And, if they go in and find something and do something, then they can re-code it after the fact. This is how it is supposed to work based on what I've heard from this close friend.

This is correct! Unless they find pre-cancerous polyps or something wrong during colonoscopy, it's defined as preventive screening.

[cisvp]

I'm in the exact same situation. I think we're gonna get hosed.

This is why I wish Bogleheads had upvotes. Consider this one from me.

Same here

[desiderium]

Screening means it is being done for no reason except that it is the first colonoscopy in someone age 45 or it has been 10 years, or for a few other criteria involving particular risk factors (young first degree family member with colon cancer, ulcerative colitis, certain genetic cancer susceptibility syndromes). If there is any positive reason to do the exam, such as symptoms, a positive stool blood test or a follow up on previously removed precancerous polyps, then it is by definition not a screening exam.

Yes, insurance companies parse these definitions carefully. Cancer screening is supposed to be free, while everything else shifts the cost burden to patients.

[Carl53]

Family history of now two immediate family members with colon cancer has had me with five year colonoscopies for twenty plus years. One precancerous polyp early on and one again last year and now they say I'm due for another in 3 years. Don't think I've ever have had insurance not cover it in full. Medicare Part G for the last two.

[GoldStar]

Screening colonoscopies are only covered once every 10 years.

This is not generally true. At least not in my world. For my insurance they cover once every 10 years with no family history and no findings in a prior colonoscopy. If you have family history of problems or polyps were found in a prior screening they recommend and cover it every 5 years.

[toddthebod]

...
If it hasn't been done, your options are:
1. Pay for it.
2. Switch health plans during open enrollment, then have your colonoscopy next year.
3. Cancel your appointment.
4. Wait until it's been 10 years and find a new doctor who will bill it as a screening colonoscopy.

Regarding option 2, I guess you're saying the "once per 10 years" limit is per insurer. I would be pleasantly surprised if true. This might still require certain procedure codes.

No, I'm saying choose a non-HDHP.

[toddthebod]

Screening colonoscopies are only covered once every 10 years.

This is not generally true. At least not in my world. For my insurance they cover once every 10 years with no family history and no findings in a prior colonoscopy. If you have family history of problems or polyps were found in a prior screening they recommend and cover it every 5 years.

I should have specified, the ACA only mandates a screening colonoscopy every 10 years, as that is the USPSTF recommendation.

[toddthebod]

Family history of now two immediate family members with colon cancer has had me with five year colonoscopies for twenty plus years. One precancerous polyp early on and one again last year and now they say I'm due for another in 3 years. Don't think I've ever have had insurance not cover it in full. Medicare Part G for the last two.

People are having a hard time in this thread understanding the difference between insurance coverage and ACA-mandated preventative services.

Insurance will have no problem covering his colonoscopy, once he meets his deductible. What they won't do is cover an additional colonoscopy in the 10 year window without any co-pay, deductible, or cost-sharing.

And Medicare has their own rules:
https://www.medicare.gov/coverage/colonoscopies

[Tycoon]

First one was $0.00. Second one 5yrs. later was $0.00. Third one at 10 yrs. cost nearly four grand. If the doctor/administrator chooses to code it as preventative the cost will be $0.00. If the doctor/administrator chooses to code it as diagnostic there will be a bill. Oh, and I've never exhausted my yearly deductible, ever.

I cancelled the initial second procedure because the doctor/administrator wouldn't code it as preventative and found a doctor/administrator that would. Laziness prevented me from doing it again for the third procedure.

[fujiters]

If you're pretty sure it's not going to count as a screening colonoscopy (and get covered by insurance due to ACA requirement), you may want to consider paying out of pocket and using Colonoscopy Assist. In many cases, you can get a rate lower than the insurance negotiated rate and you're guaranteed not to have a higher cost even if polyps are removed during the procedure.

[Kenkat]

Screening colonoscopies are only covered once every 10 years.

This is not generally true. At least not in my world. For my insurance they cover once every 10 years with no family history and no findings in a prior colonoscopy. If you have family history of problems or polyps were found in a prior screening they recommend and cover it every 5 years.

This has been my experience so far on my insurance plan. I have one more 5 year interval coming up early next year - I will see if it’s covered but I hopeful it will be as the last two were.

[Kenkat]

Regarding option 2, I guess you're saying the "once per 10 years" limit is per insurer. I would be pleasantly surprised if true. This might still require certain procedure codes.

No, I'm saying choose a non-HDHP.

Of the plan choices I have, with the non-HDHP, you end up just paying the deductible in the form of higher premiums over the course of the year. They all come out fairly close in terms of cost whether you need care or not during the year.

[MGBMartin]

A few years back I did the Cologuard thing which came back positive.
PCP referred me to GI for a colonoscopy but then I started reading about insurance and Cologuard and colonoscopy and it seemed confusing.
I had the colonoscopy for which I had to pay a copayment. Turned out I had so many polyps the GI doc couldn’t get them all so he scheduled a second colonoscopy a few months later for which I once again paid the copayment.
Insurance paid everything without issue or questions.

Updating this as my told I didn’t have to pay any copays.
The first colonoscopy the facility said I had to pay $125 copay which I thought at the time was odd because I thought I didn’t have to pay one. Surprisingly the facility sent me a check about a week later refunding the payment I had made telling me they had mistakenly charged the copay.
The second colonoscopy at the same facility, same person checking me in too, and no mention of a copay needed.

[cks]

Each insurance company has their own set of coverage and reimbursement policies, and sometimes among different plans within its own policies. Look at this disclaimer from one of the major insurers about a coverage policy:

"This Medical Policy provides assistance in interpreting UnitedHealthcare standard benefit plans. When deciding coverage,
the member specific benefit plan document must be referenced as the terms of the member specific benefit plan may
differ from the standard plan. In the event of a conflict, the member specific benefit plan document governs. Before using
this policy, please check the member specific benefit plan document and any applicable federal or state mandates.
UnitedHealthcare reserves the right to modify its Policies and Guidelines as necessary. This Medical Policy is provided for
informational purposes. It does not constitute medical advice."



The whole experience is c**p.

[ChicagoBear7]

If you have employer provided insurance, there can be huge differences in coverage depending upon whether your employer is "self insured" or not. My employer, a large financial institution, is self insured as has decided to fully cover all colonoscopies. It would rather pay for diagnostic procedures for polyp producers than bowel resections and chemo because someone put off getting necessary treatment.

[Zosima]

This is not generally true. At least not in my world. For my insurance they cover once every 10 years with no family history and no findings in a prior colonoscopy. If you have family history of problems or polyps were found in a prior screening they recommend and cover it every 5 years.

This has been my experience so far on my insurance plan. I have one more 5 year interval coming up early next year - I will see if it’s covered but I hopeful it will be as the last two were.

Same experience here. I have a HDHP an am on the five-year schedule because they keep finding pre-cancerous polyps and the first two have been covered without any deductible. I am three years away from the next one so hopefully it will be covered again.

From the insurance company's perspective, it is likely cheaper to cover the screening and polyp removal than to deal with a later cancer treatment.

[delbcavista]

Not a doctor, but have history of polyps in family so have some experience. Our family does routine colonoscopies more regularly than every ten years due to family history of pre cancerous polyps. We are, however, willing to pay whatever it costs due to the importance of these screenings based on history so we don't think twice about it. These screenings are imperative for prevention and we feel it's important to stick to the timeline dictated by a doctor. Something to ask about insurance is what the cost is for the anesthesia. Sometimes they outsource the anesthesiologist and even if the colonoscopy is in network or covered, the anesthesiologist can be out of network bringing a hefty bill.

[JPM]

A screening colonoscopy is one that is done for screening purposes only. That means the patient has had no symptoms, no suspicious family history, and no prior abnormal exam (e.g no prior abnormal colonoscopy or Cologuard). Most insurance plans provide screening colonoscopies without a copay to encourage people to have this disagreeable but beneficial exam. Any colonoscopy that does not meet the above criteria is a diagnostic colonoscopy.

A diagnostic colonoscopy comes with a copay and is not "free" to the patient as a screening exam may be. It is covered and the patient does receive the discount as negotiated by the insurance plan.

A diagnostic colonoscopy 5 years following a colonoscopy with one or more polypectomies is a preventive service, in that it prevents the development of colon cancer by removing precancerous polyps, but it is not a screening exam. Usually a followup colonoscopy done under such circumstances entails removal of one or more polyps as part of the procedure.

If I were to have a colonoscopy with no polyps found on my followup colonoscopies, I would be delighted and happy to pay the copay and get a ten year reprieve before the next one. No such luck so far.

If you have a high deductible plan, you have to expect to have to come up with the high deductible some years, that's insurance for you.

[UALflyer]

Under the ACA bill which made colonoscopies “free” providers are not to submit colonoscopies as diagnostic even if they find polyps if you’re not having symptoms - although they try. Here’s a link from NPR which discuss the issue in more detail with suggested actions:
https://www.npr.org/transcripts/1101861735

The NPR link above is not entirely correct. As far as I know, the Affordable Care Act does not say anything about colonoscopies (a colonoscopy is just one of several types of colorectal screenings) or colorectal screenings in general. Instead, its requirement for preventive care being covered without any copays or co-insurance requirements ties to something called the US Preventive Task Force ("USPTF") recommendations, specifically the A and B ones. Hence, the reason that if you were to read your summary plan description, you'll frequently see that instead of a list of specific services deemed to be preventive, the summary plan description may just say that the health plan will cover as preventive those services listed as A and B by the USPTF.

Here is what the USPTF says about colorectal screenings: https://www.uspreventiveservicestaskfor ... -screening

So, it's not just about symptoms. This is the reason that if you use something like Cologuard (and the screening otherwise satisfies the USPTF A or B recommendation), it'll be covered 100%. If it detects something, however, even in the absence of any symptoms you'll need to have a colonoscopy for polyp removal, at which point it'll no longer be preventive, so it'll be subject to co-pay and co-insurance (Medicare has a separate twist on this). On the other hand, if instead of Cologuard, you had gone in for a colonoscopy in the first place, it would've been treated as a preventive procedure, so the whole thing, including potential polyp removals during the colonoscopy, would've been covered 100%.

Providers generally get paid the same regardless of whether a colorectal screening procedure is diagnostic or preventive, so there is no incentive for them to "try" to characterize it a certain way.

As you can see in the USPTF recommendations, there is not much clarity regarding the way that subsequent screenings should be handled if a prior screening caused the subsequent screening interval to be shortened. Hence, there is no consistency in the way that different insurance carriers handle this situation.

[coffeeblack]

Hi everyone,

I’m 57 years old and have a colonoscopy scheduled. Although I don’t have any symptoms, my primary care doctor recommended it since my last one was almost six years ago. My gastroenterologist informed me that the procedure won’t be fully covered and will count toward my deductible because I’m on a high-deductible plan. When I reached out to my insurance, they said the gastroenterologist has billed it as a diagnostic procedure (Z86.010) with the colonoscopy code 45380. The doctor explained that because my previous colonoscopy showed possible pre-cancerous polyps, it needs to be coded as diagnostic. However, since I don’t have any symptoms this time, shouldn’t this be considered a routine screening? Have any of you gone through similar situation and is this correct when I read everywhere that pre existing conditions are covered? Also, the doctor told me after 10 years from first scan, they will cover 100%
Thanks!
CVS

This is not medical advice.
Yes, it's is diagnostic. He is attempting to find out if those pre cancerous polyps have become something worse. It does not matter if you have symptoms or not.

[UALflyer]

I know someone with Ulcerative Colitis. This person has to fight this exact mis-coding every few years. Unless they are removing a polyp, my impression is that this procedure should be covered under preventative care. And, if they go in and find something and do something, then they can re-code it after the fact. This is how it is supposed to work based on what I've heard from this close friend.

This is correct! Unless they find pre-cancerous polyps or something wrong during colonoscopy, it's defined as preventive screening.

This is incorrect. A link to the USPTF official recommendation is found in my post above. If a colonoscopy satisfies the USPTF A or B requirements, its findings do not change the preventive nature of the procedure.

On the other hand, if a colonoscopy, or any other type of colorectal screening, does not satisfy the USPTF A or B requirements, in the absence of a broader provision in your particular health plan, the expense will be subject to co-pay and co-insurance regardless of its outcome.

[Sandtrap]

Hi everyone,

I’m 57 years old and have a colonoscopy scheduled. Although I don’t have any symptoms, my primary care doctor recommended it since my last one was almost six years ago. My gastroenterologist informed me that the procedure won’t be fully covered and will count toward my deductible because I’m on a high-deductible plan. When I reached out to my insurance, they said the gastroenterologist has billed it as a diagnostic procedure (Z86.010) with the colonoscopy code 45380. The doctor explained that because my previous colonoscopy showed possible pre-cancerous polyps, it needs to be coded as diagnostic. However, since I don’t have any symptoms this time, shouldn’t this be considered a routine screening? Have any of you gone through similar situation and is this correct when I read everywhere that pre existing conditions are covered? Also, the doctor told me after 10 years from first scan, they will cover 100%
Thanks!
CVS

myself
age 72
Medicare Original
Highest best gap coverage and supplementals.
Had several of these procedures. Mayo Center in Scottsdale. "paid nothing".

j

[ModifiedDuration]

Hi everyone,

I’m 57 years old and have a colonoscopy scheduled. Although I don’t have any symptoms, my primary care doctor recommended it since my last one was almost six years ago. My gastroenterologist informed me that the procedure won’t be fully covered and will count toward my deductible because I’m on a high-deductible plan. When I reached out to my insurance, they said the gastroenterologist has billed it as a diagnostic procedure (Z86.010) with the colonoscopy code 45380. The doctor explained that because my previous colonoscopy showed possible pre-cancerous polyps, it needs to be coded as diagnostic. However, since I don’t have any symptoms this time, shouldn’t this be considered a routine screening? Have any of you gone through similar situation and is this correct when I read everywhere that pre existing conditions are covered? Also, the doctor told me after 10 years from first scan, they will cover 100%
Thanks!
CVS

myself
age 72
Medicare Original
Highest best gap coverage and supplementals.
Had several of these procedures. Mayo Center in Scottsdale. "paid nothing".

j

Original Medicare has special rules for screening colonoscopies.

Medicare covers screening colonoscopies 100% if no polyps are found.

If polyps are found, then there is a 15% copay (the Part B $257 annual deductible does not apply). If you have Medicare Supplement Plans F, G, or N, the Plan would pick up that 15%.

Since polyps were found on a previous colonoscopy, I am on a five-year schedule.

https://www.medicare.gov/coverage/colonoscopies

[Sandtrap]

myself
age 72
Medicare Original
Highest best gap coverage and supplementals.
Had several of these procedures. Mayo Center in Scottsdale. "paid nothing".

j

Original Medicare has special rules for screening colonoscopies.

Medicare covers screening colonoscopies 100% if no polyps are found.

If polyps are found, then there is a 15% copay (the Part B $257 annual deductible does not apply). If you have Medicare Supplement Plans F, G, or N, the Plan would pick up that 15%.

Since polyps were found on a previous colonoscopy, I am on a five-year schedule.

https://www.medicare.gov/coverage/colonoscopies

excellent info.
thanks.
j

[cheese_breath]

...The doctor explained that because my previous colonoscopy showed possible pre-cancerous polyps, it needs to be coded as diagnostic. However, since I don’t have any symptoms this time, shouldn’t this be considered a routine screening? ...

But you do have symptoms. They're called polyps. They mght not be bothering you yet. but they're symptoms.

[SpaghettiLegs]

The screening requirements are different depending on your risk. If you had no polyps on your last one and no other significant risk factors, consensus is generally you should get screened again in 10 years. If you had polyps on the last one, and those are typically removed and examined for cancer at time of the screening, your risk is higher and the screening interval typically decreases (usually 5 years, sometimes 3 or less). When a colonoscopy is done, the gastroenterologist typically provides the patient a summary, including a recommendation for when the next one should be done.

IMO, which may or may not be professional, your upcoming colonoscopy should be considered a screen. Remember, it’s screening for cancer and as far as is known, you don’t have and have never had colon cancer.

[bumblebh]

Anyone interested in what ChatGPT thinks about this question?

1. If the Colonoscopy is for Surveillance (Diagnostic/Follow-Up)
If the patient has a history of polyps (Z86.010) and is undergoing a follow-up colonoscopy, it should be coded as diagnostic, not a screening.
CPT Code:
45378 – Diagnostic Colonoscopy (if no biopsy or polyp removal)
45380 – Colonoscopy with Biopsy
45385 – Colonoscopy with Polypectomy (snare technique)
Other codes may apply depending on findings and procedures performed.
ICD-10 Code:
Z86.010 – Personal history of colonic polyps
K63.5 – If polyps are found and documented

2. If the Colonoscopy is a Preventive Screening
Medicare and many insurers do not classify it as a true screening if the patient has a history of polyps. Instead, it’s considered a surveillance colonoscopy, meaning it’s covered under diagnostic benefits.
CPT Code:
45378 (if normal, no polyps removed)
Other CPT codes as appropriate if polypectomy, biopsy, or other interventions are performed
ICD-10 Code:
Z86.010 – History of polyps (primary diagnosis)

3. If It’s a Screening for a Patient with No Prior History of Polyps
CPT Code:
G0121 – Screening colonoscopy for average-risk Medicare patients
45378 – Screening colonoscopy (commercial insurance)
ICD-10 Code:
Z12.11 – Screening for malignant neoplasm of the colon

Key Takeaways:
Use Z86.010 for a history of polyps in surveillance colonoscopy.
Do not code it as a screening (Z12.11) if there is a prior history of polyps.
Use appropriate CPT codes depending on whether it’s diagnostic, with biopsy, or with polypectomy.

[SpaghettiLegs]

...The doctor explained that because my previous colonoscopy showed possible pre-cancerous polyps, it needs to be coded as diagnostic. However, since I don’t have any symptoms this time, shouldn’t this be considered a routine screening? ...

But you do have symptoms. They're called polyps. They mght not be bothering you yet. but they're symptoms.

Polyps are not symptoms. Definition of symptoms is available on line.

[InvestorHowie]

DW has had two, I've had one. All within five years. Pre-cancerous polyp removals with each. On a HDHP. UHC paid 100% of the post-plan discount for all of the above. Hoping for the same when I need to return in a couple years.

[cvsvm2007]

DW has had two, I've had one. All within five years. Pre-cancerous polyp removals with each. On a HDHP. UHC paid 100% of the post-plan discount for all of the above. Hoping for the same when I need to return in a couple years.

Thanks for all the responses.

@investorHowie For the first colonoscopy, the insurance covered since I was 50+. Subsequent ones, they will say it has to come from deductibles since people with with pre-cancerous is considered high risk. My PCP even told me, "they got you"

[Big Dog]

I’ve had 3 colonoscopies about 5 years apart. The last two were done because I had polyps. They were all benign but a
time span shorter than 10 years is indicated if polyps are found. All procedures were covered without any fees - maybe one had a small co-pay of $60.

My first colonoscopy found pre-cancerous polyps. No charge to me. The 2nd, 3 years later, also found polyps, no charge to me. The 3rd, 4 years later found nothing, no charge to me. (now on the 5-year plan). All were covered by insurance in full, under ACA preventive care. I had no out of pocket charge. My wife has had a similar experience with polyps and no charges. We do not have a HD plan, however, just typical 80:20 PPO.

I'd find a different Gastro if they wouldn't bill it under the ACA preventive.

[whodidntante]

It won't be free.