Does your insurance plan cover a pre-procedure evaluation and management (E/M) service associated with screening colonoscopies? According to the Centers for Medicare and Medicaid, the answer is “no”.

“Section 1862(a)(1)(A) of the Social Security Act states that no payment may be made for items or services that are not reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Section 1862(a)(7) ‘prohibits payment for routine physical checkups’.

Taken together, these sections prohibit payment for routine screening services, i.e. those services furnished in the absence of signs, symptoms, complaints, or personal history of disease or injury. The only exceptions are screening services that are specifically authorized by statute, such as colorectal cancer screening tests covered under 1861(s)(2)(R). While the law specifically provides for a screening colonoscopy, it does not also specifically provide for a separate screening visit prior to the procedure. Thus, a pre-procedure visit performed on an asymptomatic patient prior to a screening colonoscopy is not covered under current law.”1

The Four Categories of Items and Services Not Covered Under the Medicare Program and Applicable Exceptions

The following four categories of items and services not covered under the Medicare Program are discussed in the CMS publication :2

  1. Services and supplies that are not medically reasonable and necessary;
  2. Non-covered items and services;  
  3. Services and supplies that have been denied as bundled or included in the basic allowance of another service; and
  4. Items and services reimbursable by other organizations or furnished without charge.

“Where applicable, exceptions (items and services that may be covered) are also included in this discussion.

Services and Supplies That Are Not Medically Reasonable and Necessary

Services and supplies that are not medically reasonable and necessary to the overall diagnosis and treatment of the beneficiary’s condition will not be covered. Some examples include:

  • Services furnished in a hospital that, based on the beneficiary’s condition, could have been furnished in a lower-cost setting (for example, the beneficiary’s home or a nursing home);
  • Hospital services that exceed Medicare length of stay limitations;
  • Evaluation and management services that exceed those considered medically reasonable and necessary;
  • Therapy or diagnostic procedures that exceed Medicare usage limits;
  • Screening tests, examinations, and therapies for which the beneficiary has no symptoms or documented conditions, with the exception of certain screening tests, examinations, and therapies as described on page 2 under Exceptions;
  • Services not warranted based on the diagnosis of the beneficiary (for example, acupuncture and transcendental meditation); and
  • Items and services administered to a beneficiary for the purpose of causing or assisting in causing death (assisted suicide).

In general, Medicare-covered services are those services considered medically reasonable and necessary to the overall diagnosis or treatment of the beneficiary’s condition or to improve the functioning of a malformed body member. Services or supplies are considered medically necessary if they meet the standards of good medical practice and are:

  • Proper and needed for the diagnosis or treatment of the beneficiary’s medical condition;
  • Furnished for the diagnosis, direct care, and treatment of the beneficiary’s medical condition;
  • Not mainly for the convenience of the beneficiary, provider, or supplier.

Services must also meet specific medical necessity criteria defined by National Coverage Determinations and Local Coverage Determinations. For every service billed, the specific sign, symptom, or beneficiary complaint necessitating the service must be indicated. Although furnishing a service or test may be considered good medical practice, Medicare generally prohibits payment for services without beneficiary symptoms or complaints or specific documentation”.3

The American College of Gastroenterology asked the Physician Regulatory Issues Team (PRIT) if there are circumstances when Medicare might pay for a pre-procedure E/M visit prior to a scheduled screening colonoscopy. PRIT responded:

“Medicare coverage is permitted for services which are ‘reasonable and necessary for the diagnosis or treatment of illness or injury’ by law (Title 18 of the Social Security Act 1862(a)(1)(A)) and therefore a pre-colonoscopy E&M which meets this requirement will normally be covered. An E&M visit which does not meet this reasonable and necessary standard is defined as non-covered by the law. Only congress can allow exceptions to this reasonable and necessary standard by creating a special benefit category as it has for each of the preventative benefits now covered by Medicare.”4

Third-party payers that do not follow Medicare guidelines may reimburse a surgeon for an E/M service prior to a screening colonoscopy. For private insurances, coders will need to address this question with each carrier's representative prior to billing these services. 

1. Social Security. Vol. II, P.L. 108-173, §953(b).
2. Jan. 2015.


About the author

web2pro Business Performance Services offers services and consulting to help hospitals, health systems, and physician practices improve business performance, boost margins and transition successfully to value-based care.