In the under 65 health insurance market (including group), rules can vary by carrier.
I have been involved in claims on appeal, but have never seen one reversed where changing the CPT code from treatment performed to a code that does not agree with the medical notes, would be allowed.
In this case, a polyp was found and (presumably) removed for biopsy. If so, that is not usually considered a "routine screening". A surgical procedure (removing the polyp) and lab test on the polyp was performed.
EDIT
When is a Screening Colonoscopy Free?
A Screening Colonoscopy is free of charge if you are age 50+, or considered to be at high risk for Colon Cancer at less than age 50, and covered under an insurance plan that is accepted at Digestive Care Physicians.
The procedure is considered to be a Screening ONLY if no symptoms of Colon Cancer are detected during the procedure. This means that no Polyps or abnormal tissues are detected or removed.
When is a Colonoscopy Not Free?
If Polyps are removed for laboratory analysis during a Screening Colonoscopy procedure, it automatically becomes a Diagnostic Colonoscopy. Also, if a patient reports symptoms such as Rectal Bleeding or Chronic Diarrhea prior to a Screening Colonoscopy, even if no Polyps are found, it may be coded as Diagnostic to determine the cause of a problem. Learn more+
If you have had a free Screening Colonoscopy within the last 10 years and the result indicated you had Colon Polyps, you are no longer eligible for a Screening Colonoscopy. You now have a prior history of Colon Polyps so your next Colonoscopy is considered Surveillance of the Colon and possibly Diagnostic.
Patients that do not have insurance can take advantage of our Self-Pay program for a Screening Colonoscopy. If you are under age 50, you may not be eligible for a free Screening Colonoscopy unless you are considered to be at high risk for Colon Cancer. Patients should contact their insurance company for prior approval.
What Makes a Screening Colonoscopy Become Diagnostic and Not Free?
A Diagnostic Colonoscopy occurs when sample tissue is taken to diagnose an unusual or abnormal looking growth or section of tissue during a Screening Colonoscopy. Once tissue is taken, a Screening Colonoscopy becomes Diagnostic. Any symptom such as change in bowel habits, Diarrhea, Constipation, Rectal Bleeding, anemia, etc. prior to the procedure and noted as a symptom in your medical records may also indicate that a Diagnostic Colonoscopy is needed.
Patients that have a family history of Polyps or Colon Cancer may require Surveillance of the Colon with continuous observation or testing. Surveillance of the Colon is considered Preventive ONLY if the patient is being observed because of risk factors (e.g., work environment) or due to family history.
Surveillance of the Colon is considered Medical if it is being done to observe or monitor a known symptom or problem.
If you have had a Screening Colonoscopy within the last 10 years and the result indicated you had Colon Polyps, you are not eligible for a Screening Colonoscopy. You now have a prior history of Colon Polyps so your next Colonoscopy is now considered Surveillance of the Colon and possibly Diagnostic.
https://digestivecarephysicians.com/will-my-colonoscopy-be-free-of-charge
I have been involved in claims on appeal, but have never seen one reversed where changing the CPT code from treatment performed to a code that does not agree with the medical notes, would be allowed.
In this case, a polyp was found and (presumably) removed for biopsy. If so, that is not usually considered a "routine screening". A surgical procedure (removing the polyp) and lab test on the polyp was performed.
EDIT
When is a Screening Colonoscopy Free?
A Screening Colonoscopy is free of charge if you are age 50+, or considered to be at high risk for Colon Cancer at less than age 50, and covered under an insurance plan that is accepted at Digestive Care Physicians.
The procedure is considered to be a Screening ONLY if no symptoms of Colon Cancer are detected during the procedure. This means that no Polyps or abnormal tissues are detected or removed.
When is a Colonoscopy Not Free?
If Polyps are removed for laboratory analysis during a Screening Colonoscopy procedure, it automatically becomes a Diagnostic Colonoscopy. Also, if a patient reports symptoms such as Rectal Bleeding or Chronic Diarrhea prior to a Screening Colonoscopy, even if no Polyps are found, it may be coded as Diagnostic to determine the cause of a problem. Learn more+
If you have had a free Screening Colonoscopy within the last 10 years and the result indicated you had Colon Polyps, you are no longer eligible for a Screening Colonoscopy. You now have a prior history of Colon Polyps so your next Colonoscopy is considered Surveillance of the Colon and possibly Diagnostic.
Patients that do not have insurance can take advantage of our Self-Pay program for a Screening Colonoscopy. If you are under age 50, you may not be eligible for a free Screening Colonoscopy unless you are considered to be at high risk for Colon Cancer. Patients should contact their insurance company for prior approval.
What Makes a Screening Colonoscopy Become Diagnostic and Not Free?
A Diagnostic Colonoscopy occurs when sample tissue is taken to diagnose an unusual or abnormal looking growth or section of tissue during a Screening Colonoscopy. Once tissue is taken, a Screening Colonoscopy becomes Diagnostic. Any symptom such as change in bowel habits, Diarrhea, Constipation, Rectal Bleeding, anemia, etc. prior to the procedure and noted as a symptom in your medical records may also indicate that a Diagnostic Colonoscopy is needed.
Patients that have a family history of Polyps or Colon Cancer may require Surveillance of the Colon with continuous observation or testing. Surveillance of the Colon is considered Preventive ONLY if the patient is being observed because of risk factors (e.g., work environment) or due to family history.
Surveillance of the Colon is considered Medical if it is being done to observe or monitor a known symptom or problem.
If you have had a Screening Colonoscopy within the last 10 years and the result indicated you had Colon Polyps, you are not eligible for a Screening Colonoscopy. You now have a prior history of Colon Polyps so your next Colonoscopy is now considered Surveillance of the Colon and possibly Diagnostic.
https://digestivecarephysicians.com/will-my-colonoscopy-be-free-of-charge
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