Skip to main content

The Difference Between a Screening and Diagnostic Colonoscopy.

Many patients are confused by the difference between a screening and a diagnostic colonoscopy.  While the actual procedure is the same, the distinction between the two depends on why the colonoscopy is being done.  While you might think that I am wading into a sea of nonsense and absurdity, I am offering you a glimpse of the rational and reasonable world of medical insurance!  Try to follow along.

Here’s a primer.

A screening exam means that you have no symptoms or relevant laboratory or x-ray abnormalities that justify a colonoscopy.  Consider this to be a simple check-up for your colon.  You are being screened to determine if you have a hidden abnormality or lesion.  Get it? 

A diagnostic exam means that the doctor is investigating an existing or suspected abnormality. A medical condition is under consideration and a colonoscopy is advised to investigate.   For example, if you have bowel symptoms, weight loss, blood in the stool, a personal history of colon polyps or a CAT scan that shows an abnormal intestine, then your colonoscopy will be considered diagnostic, not screening.   Get it? 

Large Intestinal in diameters

Diagnostic or Screening?
It's a Question of Motive.

Why does this even matter?   Do not expect that my response will make sense to you, since it makes no sense to me, and I’ve been in the business for a few decades.

In general, most insurance companies will cover screening colonoscopies fully, but most diagnostic colonoscopies will be subject to deductibles and co-insurance.  In other words, even though a diagnostic colonoscopy is the exact same test in every way as a screening exam, the diagnostic version may cost patients more.  Make sense?  If so, please leave a comment so you can explain it to me. 

And, permit me to offer an example when the absurd transforms into the insane.  If a polyp is found on a screening colonoscopy, then the procedure will be changed from a screening to a diagnostic colonoscopy automatically!  So, such a patient who believed that his screening procedure will be fully covered, may have a $urpri$e awaiting him.  The federal government's position that even if a polyp is a discovered, this should not impact patients financially, although not all insurance carriers are on board with this.

Before you have your colonoscopy, it is important to contact your insurance company about your benefits so that you understand the coverage prior to undergoing the procedure.  Ask if your financial obligation changes if a polyp is removed or any biopsies are taken.   I always advise that you write down the name of the insurance company representative and make some notes of the conversation just in case. 

On occasion, patients will contact us after the fact and ask us to change our code from diagnostic to screening, for reasons that readers will now understand.   While we may sympathize with their plight, we are not in the business of altering medical records or otherwise gaming the system. Such behavior would risk a whistleblower turning me in.   

Comments

  1. Hrmm. Makes me wonder where CHEK2 falls on this. I've also been told that needing a colonoscopy after a Cologuard result makes it diagnostic and not a screening as well. Apparently a lot of folks have been surprised by the bill.

    ReplyDelete
  2. @Pinata of Path. Appreciate your response. Yes, you are correct that a colonoscopy that follows a positive Cologuard or other abnormal stool test is a diagnostic study, although GI societies are trying to address this. Welcome to the Theater of the Absurd!

    ReplyDelete
  3. Progress is just around the corner! https://www.mdedge.com/internalmedicine/article/256173/gastroenterology/medicare-cover-colonoscopy-after-positive-fecal?ecd=WNL_eve_220711_mdedge

    ReplyDelete

Post a Comment

Popular posts from this blog

Why Most Doctors Choose Employment

Increasingly, physicians today are employed and most of them willingly so.  The advantages of this employment model, which I will highlight below, appeal to the current and emerging generations of physicians and medical professionals.  In addition, the alternatives to direct employment are scarce, although they do exist.  Private practice gastroenterology practices in Cleveland, for example, are increasingly rare sightings.  Another practice model is gaining ground rapidly on the medical landscape.   Private equity (PE) firms have   been purchasing medical practices who are in need of capital and management oversight.   PE can provide services efficiently as they may be serving multiple practices and have economies of scale.   While these physicians technically have authority over all medical decisions, the PE partners can exert behavioral influences on physicians which can be ethically problematic. For example, if the PE folks reduce non-medical overhead, this may very directly affe

Should Doctors Wear White Coats?

Many professions can be easily identified by their uniforms or state of dress. Consider how easy it is for us to identify a policeman, a judge, a baseball player, a housekeeper, a chef, or a soldier.  There must be a reason why so many professions require a uniform.  Presumably, it is to create team spirit among colleagues and to communicate a message to the clientele.  It certainly doesn’t enhance professional performance.  For instance, do we think if a judge ditches the robe and is wearing jeans and a T-shirt, that he or she cannot issue sage rulings?  If members of a baseball team showed up dressed in comfortable street clothes, would they commit more errors or achieve fewer hits?  The medical profession for most of its existence has had its own uniform.   Male doctors donned a shirt and tie and all doctors wore the iconic white coat.   The stated reason was that this created an aura of professionalism that inspired confidence in patients and their families.   Indeed, even today

Electronic Medical Records vs Physicians: Not a Fair Fight!

Each work day, I enter the chamber of horrors also known as the electronic medical record (EMR).  I’ve endured several versions of this torture over the years, monstrosities that were designed more to appeal to the needs of billers and coders than physicians. Make sense? I will admit that my current EMR, called Epic, is more physician-friendly than prior competitors, but it remains a formidable adversary.  And it’s not a fair fight.  You might be a great chess player, but odds are that you will not vanquish a computer adversary armed with artificial intelligence. I have a competitive advantage over many other physician contestants in the battle of Man vs Machine.   I can type well and can do so while maintaining eye contact with the patient.   You must think I am a magician or a savant.   While this may be true, the birth of my advanced digital skills started decades ago.   (As an aside, digital competence is essential for gastroenterologists.) During college, I worked as a secretary