What’s the difference between a screening and a diagnostic colonoscopy?
A screening is a test provided to a patient in the absence of signs or symptoms. A screening colonoscopy is a service performed on an asymptomatic person for the purpose of testing for the presence of colorectal cancer or colorectal polyps. Whether a polyp or cancer is ultimately found does not change the screening intent of that procedure.
As part of the Affordable Care Act (ACA), Medicare and most third-party payers are required to cover services given an A or B rating by the U.S. Preventive Services Task Force (USPSTF) without a co-pay or deductible.
- Patient is 50 years of age or older
- Patient does not have any gastrointestinal sign, symptom(s), and/or relevant diagnosis
- Patient does not have any personal history of colon cancer, polyps, and/or gastrointestinal disease
- Patient may have a family history of gastrointestinal sign, symptom(s), and/or relevant diagnosis
Diagnostic colonoscopy is a test performed as a result of an abnormal finding, sign or symptom (such as abdominal pain, bleeding, diarrhea, etc.). Medicare and most payers do not waive the co-pay and deductible when the intent of the visit is to perform a diagnostic colonoscopy.
What is a surveillance colonoscopy?
A surveillance colonoscopy can be performed at varying ages and intervals based on the patient’s personal history of colon cancer, polyps and/or gastrointestinal disease. Patients with a history of colon polyp(s) are not recommended for a screening colonoscopy, but for a surveillance colonoscopy.
Per the USPSTF, “When the screening test results in the diagnosis of clinically significant colorectal adenomas or cancer, the patient will be followed by a surveillance regimen and recommendations for screening are no longer applicable.”
The USPSTF does not recommend a particular surveillance regime for patients who have a personal history of polyps and/or cancer; however, surveillance colonoscopies generally are performed in shortened intervals of two to five years. Medical societies, such as the American Society of Colon and Rectal Surgeons and the American Society of Gastrointestinal Endoscopy, regularly publish recommendations for colonoscopy surveillance.
Surveillance colonoscopies are most often covered under diagnostic benefits, even if the patient is asymptomatic. Guidelines are inconsistent across payers; check with your individual payers for their guidelines.
