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Will My Procedure Be Covered By Insurance? 


As we encourage our patients to get screened during Colon Cancer Awareness Month, it’s important to provide some education regarding how these procedures are billed and processed by insurance companies.  While the Affordable Care Act (ACA) has helped to provide better benefits to patients for preventative services (like a screening colonoscopy), there are still plenty of twists and snags along the way when it comes to processing an insurance claim.

To start, there is some important terminology that needs to be understood before contacting your insurance company to find out what sort of benefits your plan provides.  Most insurances divide colonoscopies into two categories.  The first is diagnostic, which means that the patient is having a symptom like diarrhea, constipation, or rectal bleeding to name a few.  The second is screening (or preventative), which means that the patient is having the colonoscopy simply due to age and not having any symptoms.

Traditionally, a diagnostic colonoscopy is processed like any other medical charge, and can be applied to a patient’s coinsurance and deductible.  The ACA requires insurance companies to pay for screening colonoscopies at 100%, with no patient responsibility.  However, there is a third gray area – what is generally known as a high risk colonoscopy.  Insurances can consider a colonoscopy to be high risk if the patient isn’t having any symptoms, but has something in their background that is a red flag – for example, a personal history of colon polyps or cancer, or even a family history of colon polyps or cancer.  Insurances have the ability to put a high risk colonoscopy on either side of the fence as far as payment – some consider these to be screening, and others consider them to be diagnostic.

To throw one last wrench into the mix – what happens when a patient comes in for a colonoscopy as a screening, but during the procedure the doctor finds a polyp?  This is another situation where an insurance company can decide to process as either screening or diagnostic, depending on their policy.

As you’ve figured out by now, determining how your procedure will be paid before it happens can be extremely confusing.  The single most important thing that you can do is call your insurance company at least a week before your procedure to ask them exactly how your plan covers this very important test.  Below is some information that will assist you in making the call and interpreting the information that they give to you.

#1 – Procedure Codes

A procedure code (or CPT code) is a code used by physicians to tell the insurance company what exactly the doctor did during your visit.  The important procedure codes to remember when talking about screening colonoscopies include:

  • G0121    This is a procedure code which is used by Medicare and some commercial insurance carriers.  It is used to describe a screening colonoscopy done for a patient who had no symptoms prior to the procedure, was not considered high risk, and had a completely normal procedure (i.e. no polyps found).  It is covered at a frequency of every 10 years following the month in which the last screening colonoscopy was performed.
  • G0105 – This is a procedure code used by Medicare and some commercial insurance carriers.  It is used to describe a colonoscopy done for a patient who was considered to be high risk prior to the procedure (i.e. family or personal history of colon polyps or cancer, chronic inflammatory bowel disease).  As with the G0121, it is only used for a completely normal procedure.  It is covered at a frequency of once every 24 months.
  • 45378 – This is the standard procedure code for a diagnostic colonoscopy and is accepted by all insurance carriers.  It can be used in several ways.  Most often, it is used to describe a colonoscopy done for a patient who was having symptoms prior to the procedure.  It can also be used for screening and/or high risk patients whose insurance company does not accept either of the “G” codes noted above.  This is again used for a completely normal procedure only.

#2 – Diagnosis Codes

A diagnosis code (or ICD-10 code) is a code used by the physician to tell the insurance company why the doctor saw you for a visit.  The important diagnosis codes to remember when talking about screening colonoscopies include:

  • Z12.11 – screening for colorectal cancer (no other symptoms or high risk conditions)
  • Z83.71 – family history of colon polyps
  • Z80.0 –   family history of colon cancer
  • Z86.010 – personal history of colon polyps
  • Z85.038 – personal history of colon cancer
Keep in mind that family history includes first degree relatives only – that includes parents, siblings, and children.  Relatives such as grandparents, aunts/uncles, or cousins do not meet the criteria for family history.

Now that you have all of the terminology, you’re ready to call your insurance company and find out how your procedure will be covered.  First, let them know you are planning to have a colonoscopy done.  Using the list above, give them the appropriate diagnosis code for the procedure.  If more than one applies to you, give all appropriate codes to the insurance company.  They should be able to tell you (based on that information) how your procedure will be covered.  Second, ask them what happens if a polyp is found during the procedure.  Will they process the insurance claim as a screening, or will they now process as diagnostic? 

If this is not your first colonoscopy, make sure to tell your insurance company the date of your last procedure.  Most insurance companies have limitations on how often a screening colonoscopy may be done (as discussed above).

One last thing to think about when talking with an insurance company.  Some representatives will tell you something along the lines of “well, if your doctor codes it correctly, we’ll pay it as a screening at 100%, no patient responsibility”.  Be very careful how you interpret that sentence!  We are legally required to report to the insurance exactly what was done – so if we find a polyp during the procedure, we have to include that on your insurance claim.  To change or eliminate information to get a claim paid differently is considered to be insurance fraud.  We are always willing to review a claim for accuracy once it has been processed by the insurance company, and sometimes we can make simple adjustments based on the plan that you have and the codes that they accept – but we cannot make any fraudulent claims.

Our billing department is happy to answer any questions that you may have about your procedure, and they can be reached at 610-374-4401 option 4.