Understanding the Different Types of Colonoscopies

There is a lot of misunderstanding about how colonoscopies are classified to insurance companies. These categories will determine your insurance benefit coverage and can make a difference in your personal out of pocket expenses. In order to avoid an unexpected charge, it is important that you educate yourself on your specific category and your insurance policy coverage.

What is a screening colonoscopy?

You are classified for a “screening colonoscopy” if:

1. You do not have ANY gastrointestinal symptoms (such as bleeding, pain, positive screening tests, etc
2. You are age 45 and over (depending on your insurance coverage)
3. You have no personal or family history of GI disease, colon polyps, and/or cancer.
4. You have not undergone a colonoscopy within the last 10 years.

Please remember, Your primary care physician may refer you for a “screening” colonoscopy but there may be a misunderstanding of the word screening. This will be determined in the pre-operative process. Before your procedure, you can ask what category your procedure falls under and can contact your insurance company for details of coverage.

What is a Diagnostic/Therapeutic Colonoscopy?

This is a colonoscopy that is scheduled when you are having any of the following:

1. Current gastrointestinal symptoms, such as bleeding or pain
2. You have underlying GI diseases such as Crohn’s Disease or Ulcerative Colitis
3. You have iron deficiency anemia
4. You have had any abnormal tests such as a Cologuard Test, a positive blood test in your stool, etc.

What is a Surveillance/High Risk Screening Colonoscopy:

This is when you have no current symptoms, but you have had a history of polyps, or a family history of colon cancer or polyps. Patients in this category are required to undergo colonoscopy surveillance at shortened intervals (such as every 2-5 years)

Preventative Colonoscopy Screening Diagnosis:

Can Dr. Ebrahim change my records so that I can be considered eligible for colon screening?

Absolutely not, this would constitute insurance fraud. Your visit is documented as a medical record based on the information you or your referring physician have provided as well as what is obtained during taking our pre-procedure history and assessment. It is a binding legal document that cannot be changed in order to obtain better insurance coverage.

There are strict government and insurance company documentation and coding guidelines that prevent a physician from altering a chart or bill for the sole purpose of coverage determination.