type of procedure is going to be performed. Why is the patient having
the procedure done? Is it for screening purposes (for patients with no
symptoms and no history), surveillance purposes (for patients who
have a personal or family history, placing them at high risk) or is it a
diagnostic colonoscopy for symptoms?
Why is this important to know? Because the benefits for the differ-
ent types of procedures usually vary — and this could determine a
patient's out-of-pocket obligation. Case in point: Let's say the patient is
covered at 100% for a "screening" or "surveillance" procedure. But he
would owe his regular deductible and possibly a co-pay if the surgeon
does a biopsy or polypectomy procedure. Not only should you thor-
oughly understand the patient's benefits, but you should also explain
them in detail to the patient before the procedure. This way, it's not a
surprise when you ask for payment. Stress to the patient that you
won't know if he'll owe anything out-of-pocket until after the
colonoscopy. Remember, if you don't explain their benefits to them on
the front end, patients could easily think that you incorrectly billed
their procedure or are mistakenly charging them — and maybe even
that you committed fraud.
Verify the patient's insurance benefits. As a general rule, patients
having a diagnostic colonoscopy for symptoms usually owe a co-pay
and deductible, while patients having a "screening" or "surveillance" pro-
cedure are usually 100% covered. But it's still a good idea to verify insur-
ance coverage on colonoscopy cases. If the colonoscopy is scheduled as
a screening or surveillance study, check both sets of benefits and explain
the benefits for both screening and diagnostic colonoscopy procedures to
patients. If the colonoscopy is scheduled as a diagnostic colonoscopy for
symptoms, obtain benefits for a diagnostic colonoscopy — where the
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Coding & Billing
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