Screening Colonoscopy (high risk)

What it is

Some people carry a higher lifetime chance of colorectal cancer than the general population, and for them screening starts sooner and repeats more often. This code describes a screening colonoscopy performed on that basis. The examination is exactly the one done for average-risk screening — a flexible scope passed the length of the large intestine, with polyps removed as they are found — but the claim states that the patient falls into a higher-risk category rather than being screened as a matter of routine. That statement is not cosmetic. Coverage rules tie the permitted interval between screenings to it: Medicare, for instance, allows a high-risk screening colonoscopy far more frequently than an average-risk one.

Why it is done

• To follow someone who has had polyps removed before, where new ones are more likely to appear
• To monitor a colon affected by inflammatory bowel disease, where years of inflammation raise the risk
• To screen a person with close relatives who have had colorectal cancer or advanced polyps
• To screen someone with an inherited condition such as Lynch syndrome or familial adenomatous polyposis, where surveillance begins earlier in life

What to expect

Nothing about the day differs from any other colonoscopy: clear liquids and a cleansing prep beforehand, sedation during, an hour or less for the exam itself, and someone else driving home. The difference is in the pattern around it. High-risk patients are usually on a named surveillance schedule, and the doctor's report will normally set the date of the next one based on what was found. If the exam is being done because of inflammatory bowel disease, expect systematic sampling of the lining, which adds a pathology bill.

Questions worth asking

• What in my record is being used to establish high risk, and does my plan accept the same definition? Plans differ on which family histories qualify.
• Is the risk category on the doctor's claim going to match the one on the facility's claim? A mismatch between the two is a common cause of one of them being denied.
• If my plan does not recognize me as high risk, would this be processed as a screening I am not yet due for — and what would I owe then?
• When is the next one due under my plan's rules, as opposed to the interval the doctor recommends? They are not always the same.