Evaluation and Management Visit Prior to Screening Colonoscopy

Article Publication Date

08/22/2003

Article Beginning Effective Date

01/15/2003

Article Text

Per the Centers for Medicaid and Medicare Services, the primary mission of the Medical Review department is to reduce the claims payment error rate. Medical Review accomplishes this by identifying patterns of inappropriate billing, educating providers concerning Medicare coverage and coding requirements, and performing medical review. The following is a message to selected provider specialties in regards to an issue related to their field(s):

Evaluation and Management Visit prior to Screening Colonoscopy

This issue was previously addressed as part of a list serve article sent to selected specialties in June of this year and as part of July 2003 online Medicare Bulletin article.
(see http://www.cignamedicare.com/partb/bltin/all/03bltin/03_7/base_July03.html#012).

As Medicare continues to receive questions regarding the above, we are addressing this topic again as a single issue. When a provider performs a screening colonoscopy, he/she cannot also bill for a pre-procedure visit to determine the suitability of the patient for the colonoscopy. These E/M services are not separately payable. While the law specifically provides for a screening colonoscopy, it does not also specifically provide for a separate screening visit prior to the procedure. Although no separate payment can be made for these visits currently, the fee schedule payment for all procedures, including colonoscopy, contains payment for the usual pre-procedure work associated with it. This reflects the principle that each procedure has an evaluative component.

With the publication of the above, providers are advised to incorporate these guidelines into the billing of their claims so to avoid inappropriate billing and payment.