Re: Medicare Screening Colonoscopies - Waived fees and Extra fees

[Guest guest]

,I understand that diagnostic code may apply on follow-up colonoscopy for polyps found on a PRIOR colonoscopy, but when a colonoscopy is done as a screening procedure, it is still screening if it finds something (or certainly should be).  But that is me being logical.....

SharonSharon McCoy MD

Renaissance Family Medicine10 McClintock Court; Irvine, CA  92617PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax:  www.SharonMD.com

 

Had a patient complain of an interesting Medicare Billing problem for Screening Colonoscopies.He had a Screening Colonoscopy done in an outpatient hospital owned (partially) Same Day Surgery Center.

His understanding was that everything should be covered by Medicare (probably a bad assumption to start).Anyway, he got a diagnostic colonoscopy coded and says the Surgery Center bill was completely denied (I need to confirm this).

Below is my understanding of the problem.     Screening Colonoscopies are a Medicare Benefit.     If done in an outpatient clinic and coded as G0121 -- copay/coinsurance waived and deductible waived - so patient would pay nothing (yes?)

===============================================================http://www.cms.gov/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf

82270, G0104, G0105, G0121, and G0328 on or after 01/01/11:Copayment/coinsurance waivedDeductible waivedAll other codes on or after 01/01/11:

Copayment/coinsurance applies

Deductible waived===============================================================     If polyps found (or other reasons for biopsy), G0121 is converted to Diagnostic Colonoscopy CPT 45378 and treated as regular procedure -- and Copayment/coinsurance applies (although, according to the info above, it appears the deductible is waived).

     What I'm not so sure about is...prior to 2011, it appears " Beneficiary pays 20% of the Medicare approved amount after the yearly Part B deductible " (which has now been waived), but what happens to the " Beneficiary pays 25% in an ambulatory surgical center or hospital outpatient department " ?

     My particular patient had the procedure done in a Same Day Surgery Center and says that Medicare actually " denied " the Surgery Center Fee.I always hate when Medicare says something is a new benefit that is covered, then there are all these quirks to what is actually covered.

Anyone have experience with this and what to tell patients?I think some of my links below are old links (prior to 2011), so may be confusing in regards to what actually happens with the copay/coinsurance is.

My impression is....     Screening Colonoscopy done in office suite -- coinsurance/copay and deductible waived -- so no charge to patient at all.     Screening Colonoscopy done in hospital or surgery center -- 25% copay applies.

     Screening Colonoscopy converted to Diagnostic Colonoscopy -- all bets off -- Copay/Coinsurance and Deductibles apply.But I could be wrong.Thoughts?

Locke, MD============================http://www.medicare.gov/navigation/manage-your-health/preventive-services/colon-cancer-screening.aspx?AspxAutoDetectCookieSupport=1

Your costs in Original MedicareScreening Colonoscopy: You pay 20% of the Medicare-approved amount with no Part B deductible. If the test is done in a hospital outpatient department or an ambulatory surgical center, you pay 25% of the Medicare-approved amount.

http://www.medicare.gov/coverage/Search/Results.asp?State=AL%7CAlabama & Coverage=12%7CColorectal+Cancer+Screening+-+Colonoscopy & submitState=View+Results+%3E

For this screening test, the coinsurance or copayment applies, but the Medicare Part B deductible may be waived. However, if the screening test results in a biopsy or removal of a lesion or growth, the procedure is considered diagnostic and the deductible is applied. If the colonoscopy is done in a hospital outpatient department or ambulatory surgical center, you pay 25% of the Medicare-approved amount.

For more information, you may call 1-800-MEDICARE (1-).https://questions.medicare.gov/app/answers/detail/a_id/1208/~/should-i-be-tested-for-colorectal-cancer-and-does-medicare-cover-the-screening%3F

Your costs in the Original Medicare Plan?For all other screening tests, the coinsurance or copayment applies, but the Medicare Part B deductible is waived. However, if a screening test results in a biopsy or removal of a lesion or growth, the procedure is considered diagnostic and the deductible is applied. 

If the flexible sigmoidoscopy or colonoscopy is done in a hospital outpatient department or ambulatory surgical center, you pay 25% of the Medicare-approved amount.http://www.cms.gov/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf

Colorectal Cancer ScreeningG0105 – Colonoscopy (high risk)G0121 – Colonoscopy (not high risk)All Medicare beneficiaries aged 50 and older who are:• At normal risk of developing colorectal cancer; or

At high risk of developing colorectal cancer.** High risk for developing colorectal cancer is defined in 42 CFR 410.37(a)(1). See http://www.gpo.gov/fdsys/pkg/CFR-2010-title42-vol2/pdf/CFR-2010-title42-vol2-sec410-37.pdf on the Internet.

Normal risk:• Screening Colonoscopy every 10 years (unless a screening flexible sigmoidoscopy has been performed and then Medicare may cover a screening colonoscopy only after at least 47 months); andBarium Enema (as an alternative to a covered screening flexible sigmoidoscopy).

•82270, G0104, G0105, G0121, and G0328 on or after 01/01/11:•Copayment/coinsurance waivedDeductible waivedAll other codes on or after 01/01/11:•Copayment/coinsurance applies

Deductible waivedNo deductible for all surgical procedures (CPT code range of 10000 to 69999) furnished on the same date and in the same encounter as a colonoscopy, flexible sigmoidoscopy, or barium enema that were initiated as colorectal cancer screening services. 

Modifier -PT should be appended to at least one CPT code in the surgical range of 10000 to 69999 on a claim for services furnished inthis scenario.https://www.cms.gov/transmittals/downloads/R1735B3.pdf

 If during the course of the screening colonoscopy, a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than code G0105

http://www.acponline.org/running_practice/practice_management/payment_coding/medicare/pb_coding.pdf

Non-High Risk  Coverage Criteria : All beneficiaries.Frequency: Once every ten years, as long as the beneficiary has not undergone a screening flexible sigmoidoscopy within the past 48 months.  

Procedure Code: HCPCS G0121; Colon cancer screening; colonoscopy on individuals not meeting criteria for high risk12Payment Rules: If you perform a biopsy or remove a lesion, bill for a colonoscopy with biopsy or removal instead of G0121.

Beneficiary Co-payment: Beneficiary pays 20% of the Medicare approved amount after the yearly Part B deductible. Beneficiary pays 25% in an ambulatory surgical center or hospital outpatient department.

https://www.cms.gov/manuals/downloads/clm104c18.pdf60.1.1 – Deductible and Coinsurance (Rev. 1325; Issued:  08-29-07; Effective:  01-01-08; Implementation:  01-07-08) 

Prior to January 1, 2007 deductible and coinsurance apply to other colorectal procedures (G0104, G0105, G0106, G0120, and G0121). After January 1, 2007, the deductible is waived for those tests. 

NOTE:  A 25 percent coinsurance applies for all colorectal cancer screening colonoscopies (G0105 and G0121) performed in ASCs and non-OPPS hospitals effective for services performed on or after January 1, 2007.  

The 25 percent coinsurance was implemented in the OPPS PRICER for OPPS hospitals effective for services performed on or after January 1, 1999.====

[Guest guest]

in order to get paid higher any rendering service provider changes screening to

diagnostic especially if there is a polyp/diverticulum/angiodysplasia/etc found.

due diligence on the insured to find out FIRST prior to the procedure being

done. oftentimes, the patient asks for me to change the referral to a diagnostic

after the fact and asks for me to deal with rendering center which i refuse to

do so.

this is an issue between the center and the patient and 'abnormal' colonoscopy

finding.

hard to sort out. good luck.

grace

>

> Had a patient complain of an interesting Medicare Billing problem for

> Screening Colonoscopies.

>

> He had a Screening Colonoscopy done in an outpatient hospital owned

> (partially) Same Day Surgery Center.

>

> His understanding was that everything should be covered by Medicare

> (probably a bad assumption to start).

>

> Anyway, he got a diagnostic colonoscopy coded and says the Surgery Center

> bill was completely denied (I need to confirm this).

>

> Below is my understanding of the problem.

>

> Screening Colonoscopies are a Medicare Benefit.

>

> If done in an outpatient clinic and coded as G0121 --

> copay/coinsurance waived and deductible waived - so patient would pay

> nothing (yes?)

>

> ===============================================================

> http://www.cms.gov/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf

>

> 82270, G0104, G0105, G0121, and G0328 on or after 01/01/11:

> Copayment/coinsurance waived

> Deductible waived

>

> All other codes on or after 01/01/11:

> Copayment/coinsurance applies

> Deductible waived

> ===============================================================

>

> If polyps found (or other reasons for biopsy), G0121 is converted to

> Diagnostic Colonoscopy CPT 45378 and treated as regular procedure -- and

> Copayment/coinsurance applies (although, according to the info above, it

> appears the deductible is waived).

>

> What I'm not so sure about is...prior to 2011, it appears " Beneficiary

> pays 20% of the Medicare approved amount after the yearly Part B

> deductible " (which has now been waived), but what happens to the

> " Beneficiary pays 25% in an ambulatory surgical center or hospital

> outpatient department " ?

>

> My particular patient had the procedure done in a Same Day Surgery

> Center and says that Medicare actually " denied " the Surgery Center Fee.

>

> I always hate when Medicare says something is a new benefit that is

> covered, then there are all these quirks to what is actually covered.

>

> Anyone have experience with this and what to tell patients?

>

> I think some of my links below are old links (prior to 2011), so may be

> confusing in regards to what actually happens with the copay/coinsurance is.

>

> My impression is....

>

> Screening Colonoscopy done in office suite -- coinsurance/copay and

> deductible waived -- so no charge to patient at all.

>

> Screening Colonoscopy done in hospital or surgery center -- 25% copay

> applies.

>

> Screening Colonoscopy converted to Diagnostic Colonoscopy -- all bets

> off -- Copay/Coinsurance and Deductibles apply.

>

> But I could be wrong.

>

> Thoughts?

>

> Locke, MD

> ============================

>

>

http://www.medicare.gov/navigation/manage-your-health/preventive-services/colon-\

cancer-screening.aspx?AspxAutoDetectCookieSupport=1

> Your costs in Original Medicare

> Screening Colonoscopy: You pay 20% of the Medicare-approved amount with no

> Part B deductible.

> If the test is done in a hospital outpatient department or an ambulatory

> surgical center, you pay 25% of the Medicare-approved amount.

>

>

http://www.medicare.gov/coverage/Search/Results.asp?State=AL%7CAlabama & Coverage=\

12%7CColorectal+Cancer+Screening+-+Colonoscopy & submitState=View+Results+%3E

> For this screening test, the coinsurance or copayment applies, but the

> Medicare Part B deductible may be waived. However, if the screening test

> results in a biopsy or removal of a lesion or growth, the procedure is

> considered diagnostic and the deductible is applied. If the colonoscopy is

> done in a hospital outpatient department or ambulatory surgical center, you

> pay 25% of the Medicare-approved amount.

> For more information, you may call 1-800-MEDICARE (1-).

>

>

https://questions.medicare.gov/app/answers/detail/a_id/1208/~/should-i-be-tested\

-for-colorectal-cancer-and-does-medicare-cover-the-screening%3F

> Your costs in the Original Medicare Plan?

> For all other screening tests, the coinsurance or copayment applies, but

> the Medicare Part B deductible is waived.

> However, if a screening test results in a biopsy or removal of a lesion or

> growth, the procedure is considered diagnostic and the deductible is

> applied.

> If the flexible sigmoidoscopy or colonoscopy is done in a hospital

> outpatient department or ambulatory surgical center, you pay 25% of the

> Medicare-approved amount.

>

> http://www.cms.gov/MLNProducts/downloads/MPS_QuickReferenceChart_1.pdf

> Colorectal Cancer Screening

> G0105 – Colonoscopy (high risk)

> G0121 – Colonoscopy (not high risk)

>

> All Medicare beneficiaries aged 50 and older who are:

> • At normal risk of developing colorectal cancer; or

> At high risk of developing colorectal cancer.*

> * High risk for developing colorectal cancer is defined in 42 CFR

> 410.37(a)(1). See

>

http://www.gpo.gov/fdsys/pkg/CFR-2010-title42-vol2/pdf/CFR-2010-title42-vol2-sec\

410-37.pdfon

> the Internet.

> Normal risk:

> • Screening Colonoscopy every 10 years (unless a screening flexible

> sigmoidoscopy has been performed and then Medicare may cover a screening

> colonoscopy only after at least 47 months); andBarium Enema (as an

> alternative to a covered screening flexible sigmoidoscopy).

> •

> 82270, G0104, G0105, G0121, and G0328 on or after 01/01/11:

> •Copayment/coinsurance waived

> Deductible waived

>

> All other codes on or after 01/01/11:

> •Copayment/coinsurance applies

> Deductible waived

>

> No deductible for all surgical procedures (CPT code range of 10000 to

> 69999) furnished on the same date and in the same encounter as a

> colonoscopy, flexible sigmoidoscopy, or barium enema that were initiated as

> colorectal cancer screening services.

> Modifier -PT should be appended to at least one CPT code in the surgical

> range of 10000 to 69999 on a claim for services furnished inthis scenario.

>

> https://www.cms.gov/transmittals/downloads/R1735B3.pdf

> If during the course of the screening colonoscopy, a lesion or growth is

> detected which results in a biopsy or removal of the growth, the

> appropriate diagnostic procedure classified as a colonoscopy with biopsy or

> removal should be billed and paid rather than code G0105

>

>

http://www.acponline.org/running_practice/practice_management/payment_coding/med\

icare/pb_coding.pdf

> Non-High Risk

> Coverage Criteria : All beneficiaries.

> Frequency: Once every ten years, as long as the beneficiary has not

> undergone a screening flexible sigmoidoscopy within the past 48 months.

> Procedure Code: HCPCS G0121; Colon cancer screening; colonoscopy on

> individuals not meeting criteria for high risk12

> Payment Rules: If you perform a biopsy or remove a lesion, bill for a

> colonoscopy with biopsy or removal instead of G0121.

> Beneficiary Co-payment: Beneficiary pays 20% of the Medicare approved

> amount after the yearly Part B deductible. Beneficiary pays 25% in an

> ambulatory surgical center or hospital outpatient department.

>

> https://www.cms.gov/manuals/downloads/clm104c18.pdf

> 60.1.1 – Deductible and Coinsurance

> (Rev. 1325; Issued: 08-29-07; Effective: 01-01-08; Implementation:

> 01-07-08)

> Prior to January 1, 2007 deductible and coinsurance apply to other

> colorectal procedures (G0104, G0105, G0106, G0120, and G0121).

> After January 1, 2007, the deductible is waived for those tests.

>

> NOTE:

> A 25 percent coinsurance applies for all colorectal cancer screening

> colonoscopies (G0105 and G0121) performed in ASCs and non-OPPS hospitals

> effective for services performed on or after January 1, 2007.

> The 25 percent coinsurance was implemented in the OPPS PRICER for OPPS

> hospitals effective for services performed on or after January 1, 1999.

>

> ====

>

>