Colonoscopy & Procedure Coverage

Screening vs. Diagnostic Colonoscopy

How your colonoscopy is classified can affect how your insurance processes the claim.

Screening Colonoscopy

A screening colonoscopy is generally performed for colorectal cancer screening in a patient who does not have symptoms or another diagnostic reason for the procedure.

Current guidelines generally recommend colorectal cancer screening beginning at age 45 for average-risk adults. Screening may be appropriate earlier for some patients based on family history or other risk factors.

Diagnostic Colonoscopy

A colonoscopy may be considered diagnostic when it is performed to evaluate symptoms, an abnormal finding, or another medical concern, such as rectal bleeding, changes in bowel habits, or abdominal pain.

It is important to fully and accurately discuss your symptoms and medical history with your provider so that your care is appropriately documented and billed.

How Will My Insurance Process My Colonoscopy?

A provider's recommendation for colorectal cancer screening does not necessarily mean that your insurance carrier will process the procedure as a preventive service with no patient responsibility.

Your age, medical and family history, symptoms, reason for the procedure, and specific insurance benefits may all affect how your claim is processed.

If you are younger than the standard screening age, do not assume that your colonoscopy will qualify for preventive coverage. Earlier screening may be medically appropriate based on individual risk factors, but coverage varies by insurance plan.

Peninsula Gastroenterology must bill based on the medical reason for your procedure and the services actually performed. We cannot change billing or diagnosis codes solely to obtain different insurance coverage or reduce patient responsibility.

What If a Polyp Is Found During My Screening Colonoscopy?

If your colonoscopy is scheduled as a screening and a polyp is found and removed, that does not necessarily mean that the entire procedure will automatically be processed as diagnostic.

However, polyp removal, biopsy, or other services performed during the procedure may involve additional billing codes, and how those services are covered can vary by insurance plan. Your deductible, copay, coinsurance, or other cost-sharing may apply to some portion of the claim.

If your plan has different benefits for screening and diagnostic procedures, we recommend contacting your insurance carrier directly and asking:

"How does my plan cover a screening colonoscopy if a polyp is found and removed or a biopsy is performed?"

Your insurance carrier can explain how your specific benefits may apply. Peninsula Gastroenterology cannot guarantee how your insurance carrier will process the claim or determine your final out-of-pocket responsibility.

Upper Endoscopy (EGD) Is Diagnostic

An upper endoscopy, also called an EGD, is a diagnostic procedure and is not considered a preventive screening service.

Even when an EGD is performed at the same time as a screening colonoscopy, the EGD remains a separate diagnostic service and your regular medical benefits may apply, including deductible, copay, and/or coinsurance.

Having a Colonoscopy and Upper Endoscopy Together

Having a colonoscopy and upper endoscopy (EGD) during the same appointment is sometimes called a “double.”

Can I Request an EGD With My Colonoscopy?

An EGD is not automatically added to a scheduled colonoscopy simply by request. Your physician must determine that the procedure is medically necessary, and the reason for it must be documented in your medical record.

If you are interested in having both procedures, please discuss your symptoms and concerns with your physician during your office visit whenever possible. This allows your physician to determine whether an EGD is medically appropriate and whether there is a medical reason for the procedures to be performed together.

If your colonoscopy is already scheduled, please contact our office as early as possible. Last-minute requests may not be accommodated if there is not enough time to complete the necessary clinical review, documentation, insurance review, or scheduling changes.

Why Might My EGD and Colonoscopy Be Scheduled Separately?

Even when both procedures are medically appropriate, Peninsula Gastroenterology may recommend or require that they be performed on separate dates.

When an EGD and colonoscopy are performed during the same session, insurance reimbursement for the physician's professional services may be reduced because multiple procedures are being performed on the same date. Depending on the circumstances, this may affect whether our practice is able to schedule the procedures together.

If your physician determines that there is a medical reason for the procedures to be performed during the same session, they may be scheduled together when clinically appropriate.

If there is not a medical need to perform them together, our office may require the EGD and colonoscopy to be scheduled separately.

This scheduling decision is separate from whether your insurance considers each procedure covered. Both procedures may be covered services under your plan while still needing to be scheduled on different dates.

Will My Insurance Cover Both Procedures?

Coverage for a colonoscopy and EGD depends on your individual insurance plan and the medical necessity for each procedure.

An EGD is a diagnostic procedure and is not considered a preventive screening service. Even when an EGD is performed at the same time as a screening colonoscopy, your regular medical benefits may apply to the EGD and related services, including your deductible, copay, and/or coinsurance.

If the procedures are performed on separate dates, your insurance benefits and applicable patient responsibility will be applied to each date of service according to your plan.

We recommend contacting your insurance carrier if you have questions about how your benefits will apply to either procedure.

Why Do I Have a Copay for My Colonoscopy Consultation?

A consultation with a gastroenterology provider is a separate medical service from your colonoscopy.

Even when your colonoscopy is being performed for preventive colorectal cancer screening, the office consultation is billed as a specialist visit and is subject to your plan's regular specialist benefits.

Depending on your plan, a specialist copay, deductible, and/or coinsurance may apply even if your screening colonoscopy qualifies for preventive coverage.

What If My Insurance Tells Me the Visit Should Be Billed as Preventive?

We occasionally hear from patients who have been advised by their insurance carrier to ask Peninsula Gastroenterology to use a preventive code for their consultation.

Preventive services provided by a primary care provider and a gastroenterology specialist consultation are not the same service. Peninsula Gastroenterology must bill according to the services actually provided and the reason for your visit.

We cannot change billing or diagnosis codes solely to change how an insurance company processes a claim or eliminate patient cost-sharing.

If you have questions about how your specialist visit was processed, please contact your insurance carrier to review your specialist benefits and claim.