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A screening colonoscopy is only indicated for asymptomatic patients (without symptoms). When a patient presents for a colonoscopy they shouldn’t have any other sign or symptoms listed as part of the indications for performing the procedure. If a patient has any or all of the following conditions — constipation, abdominal pain and/or rectal bleeding — then the procedure would not be a screening, it would be a diagnostic service to determine the cause of their symptoms.
A surveillance colonoscopy doesn’t necessarily mean a screening colonoscopy. A previous screening colonoscopy could have identified a condition that the physician wanted to monitor or perform surveillance on, to confirm that the condition hadn’t worsened. Since there are coverage limitations (screenings once every 10 yrs. for patients not meeting the high risk criteria and once every 24 months for high risk patients) reporting another screening procedure too soon would lead to a denial of services.
Review the CMS guidelines concerning screening colonoscopy procedures for high risk patients. Two guidelines that are commonly misinterpreted are “family history of colon cancer” and “personal or family history of polyps”. Family history of colon cancer only relates to “close relatives” which are defined as siblings (brothers or sisters), parent (mother or father) or a child. Aunts, uncles and grandparents do not qualify as close relatives. When the term “history of polyps” is used as a diagnosis, you must determine the type of previous history. CMS guidelines are specific in stating that with high risk there should have been “adenomatous polyps” not hyperplastic polyps. There is very little chance if any that a hyperplastic polyp will ever develop into a cancerous state so a history of hyperplastic polyps would not put a patient in the “high risk” category.
The information provided should be utilized for educational purposes only. Facilities are ultimately responsible for verifying the reporting policies of individual commercial and MAC/FI carriers prior to claim submissions.
