COLONOSCOPY COVERAGE

Ohio Gastroenterology Group, Inc. strongly urges you to call your insurance company prior to your procedure to verify your benefits. It is possible your benefits may be different than expected or than they were in the past based on certain information. Please feel free to contact us if you have questions or concerns. 

Before your procedure

Prior Authorization & Good Faith Estimates

614-340-5097

After your procedure

Billing

614-457-4220

WHAT TO KNOW

A colonoscopy can be either a screening colonoscopy or a diagnostic colonoscopy. Although your primary care provider may refer you for a screening colonoscopy, you may not qualify for the preventative/screening benefit. Certain information can change the coverage of your procedure, such as if you have any current symptoms, a history of gastrointestinal disease (such as Crohn’s), or a personal or family history of colon cancer and/or colon polyps.

Screening Colonoscopy

The definition of a screening colonoscopy per Centers for Medicare and Medicaid Services (CMS) guidelines is as follows:
  • Patient is aged 45 years or older.
  • Patient is asymptomatic (no signs or symptoms of colorectal disease).
  • No personal history of colon polyps, colorectal cancer, or inflammatory disease.
  • No family history of colon polyps or colorectal cancer.

Diagnostic Colonoscopy

  • If you have had a colonoscopy in the past and polyps were removed, your next colonoscopy will be a surveillance of the colon, which may be considered diagnostic by some insurance plans.
  • If you have current symptoms, such as change in bowel movements, diarrhea, constipation, rectal bleeding, anemia, etc., your colonoscopy will be diagnostic.

Changing a diagnosis code to screening in cases where it is not applicable is fraudulent billing and we are unable to do so.

CHECKING WITH YOUR INSURANCE COMPANY

Before your procedure, contact your insurance carrier to verify your benefits and coverage by discussing the topics and questions below. Take notes and record the information along with the date you contacted, the representative’s name, and the call reference number.

  1. Ask what your deductible is and what amount of deductible you have met.
  2. Ask if Ohio Gastroenterology Group, Inc. is “in-network”.
  3. Let your insurance company know if you have:
    • any current symptoms;
    • a history of gastrointestinal disease (such as Crohn’s), colon cancer, or colon polyps (including if you have had colon polyps removed in the past);
    • or a family history of colon cancer or colon polyps.
  4. Ask if the procedure codes and diagnosis below are covered under your policy. Please note that the final Procedure and Diagnosis codes submitted to your insurance cannot be determined until after your procedure is done.
    • Possible Colonoscopy Procedure Codes: 45378, 45380, 45381, 45382, 45384, 45385, 45388
    • Possible Diagnoses:
      • Z12.11 – Encounter for screening colonoscopy (asymptomatic with no personal or family history of GI disease).
      • Z86.010 – Personal history of colon polyps (may be considered diagnostic by some insurance plans).
      • If you have symptoms, your colonoscopy will be diagnostic.
  5. Ask what your co-insurance responsibility and facility co-payment would be for each procedure code and diagnosis listed above.
  6. Ask if the diagnosis code will be processed as Preventative (screening) or Diagnostic?
  7. If the procedure will be preventative (screening) procedure, ask if there are age or frequency limitations for the colonoscopy?
  8. Ask if the provider removes a polyp or takes a biopsy, will it change your out-of-pocket responsibility.