The Screening Or Diagnostic Decision Of Colonoscopy

We should not ever change a code to get paid. You should be using the code because it's in the documentation, because it's the correct code to use. So we want to be sure when we talk about screening versus diagnostic testing, sometimes there is a payment differential or a different liability with the patient that we're not changing codes to benefit any individual whether it is your office or the patient.

So what's the difference between a diagnostic and screening test? Well, a screening test is used to detect or predict something for someone that has risks or has an identified possible risk. The diagnostic test is to confirm or to determine that the disease actually is there.

So when - that difference and again it has payment implications, that difference is seen and reflected in the codes that we work with.

We're going to look at Medicare first and extensively because Medicare has the best printed guidelines.  If you don't have guidelines for a particular carrier and you just do whatever you want and you get audited and you've been doing it wrong, how is that - how are you going to be able to defend yourself?

It is all about the risk, whether its high risk or low risk. Although when it comes to colorectal screenings, they are referring to it as not high risk. That would be - (illustrate that's a) low risk. So it's about high risk or not high risk. And then that guide tells us that the documentation in the medical record has to identify the risk factor for tests and procedures performed.

In that preventive guide, they do list some specific diagnoses. This is the language that refers to some tables. But also, it says that there's - it's not an all-inclusive list.

And so that opens the door for, “Okay, could this be high risk or not?” Certainly you could have a side list of initial diagnoses that you (thought were structured as) high risk. But at least they give us this much of a listing for high risk.

They have three areas that they have listed that qualify for high risk. The personal history, an inflammatory bowel code and then we have under chronic digestive disease condition where we have both an enteritis and ulcerative (colitis) problems of the colon area of (site) - of the intestine and colon area.

This is what we've looked at for a number of years that switched from the original national coverage decision that has been retired. So let's look at the codes that we're going to use for our colorectal screening. You would all know we got two codes that we use for our colorectal colonoscopy screening for high risk and then for the not high risk or individuals not meeting criteria for high risk.

Those are very equal codes from a technical standpoint. They are rather different in their reflection of the patient's risk and of considerations for frequency of payment.

Now, our guide tells us that Medicare provides coverage for all beneficiaries without regard to age or the colonoscopy except –when we look at a sigmoidostomy, they do started at age 50 and older. Risk was a very important thing to identify when these benefits came out.