The ACA colonoscopy billing violation that's all too common

Preventive colonoscopies, which are usually scheduled every 10 years starting at age 45, are supposed to be free for patients, according to the Affordable Care Act.

Hospitals and providers are allowed to change to a more expensive billing code if a colonoscopy is considered diagnostic rather than preventive, but the distinction isn't always clear. Removal of a polyp is sometimes the reason a provider changes the billing code from screening to diagnostic, Kaiser Health News reported May 31.

A patient of Lebanon, N.H.-based Dartmouth Health discovered that firsthand when she received her colonoscopy bill and was surprised to find she owed more than $2,000 after having a polyp removed during a screening, the report said. 

However, CMS has clarified multiple times that polyp removal is an integral part of screening colonoscopies and should not be considered a valid reason for a colonoscopy to be billed as a diagnostic procedure.

After Kaiser made an inquiry, a representative speaking on behalf of the health system reached out to say that the diagnosis codes had inadvertently been dropped from the system and that the patient's claim was being reprocessed, the report said.

Cigna, the patient's insurer, also reached out to Kaiser after an inquiry. A spokesperson said in a statement that the patient's claim was reprocessed and she wouldn't be responsible for any out- of-pocket costs.

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