The AGA in their GI CPT updates review states that audits have begun and take backs are happening on charges billed as routine screening colonoscopy when signs, symptoms or disease are in the medical record (personal hx of colon cancer and/or polyps is a condition). Also, I’m also thinking of the logistics of reporting screening turned diagnostic with this change (if it truly is valid). Currently a commercial high risk colon for personal hx polyps that removes a tubular adenoma by snare is reported 45385, 33 Z86.010, D12.* … it would now be reported as 45385, 33 Z12.11, Z86.010, D12.* ?? I’ve talked with many claims processors and a lot of clinical edits don’t go beyond the primary dx. It would be perceived as a routine preventive colon, not high risk.
I’m just afraid that everyone will start throwing the Z12.11 on ALL colonoscopies and payers will pay, waiving patient out of pocket, then audits will ensue and take backs will be recouped and billing departments will need to chase patients for the out of pocket expenses (and these take backs can occur years after the original billing). A personal hx of polyps, cancer, colitis, etc. allows patients to have more frequent screenings which classifies them as not routine.
Any links to literature that you’re aware of that is gold standard to support this change would be greatly appreciated. I did send a mesage to AskMueller to see if they could clarify their statement. I think payers should cover both routine and high risk colonoscopy 100% it’s ridiculous the different interpretations from payer to payer and policy to policy within the same payer. Some BCBSMi policies cover any kind of colonoscopy once a year with no patient out of pocket and then some others are grandfathered and screenings of any kind are not a benefit.
Thanks in advance for any feedback!!