Is Your Anesthesia for Colonoscopy Billing Inflating Your Medicare Patients’ Cost Sharing? 

Billing for GI Anesthesia appears to be fairly straightforward. With the main procedures being Colonoscopies and EGDs, there are only several ASA coding options to choose from. With this being the case, why are so many patients paying for coinsurance and deductible amounts that are not fully their responsibility? The answer: Incorrectly billed CPT codes and modifiers.

Legislative Background and Current Challenges

For background, the passage of the Affordable Care and Consolidated Appropriations Acts included provisions which eliminated patient cost sharing for screening colonoscopies, for both Medicare and Commercial products. In practical terms, this meant that payers would cover 100% of a colorectal cancer screening test, with no amounts being applied to a patient’s deductible or coinsurance. However, lawmakers are neither coders nor clinicians; they failed to grasp that screening colonoscopies often lead to additional diagnostic or therapeutic procedures, such as polypectomies with subsequent biopsies.

Understanding the Codes: Past and Present

For historical context, let’s consider the past and present CPT code options for this service. Prior to 2018, there was only one code available (00810) for a lower GI endoscopy anesthetic and it could represent a screening or a more comprehensive procedure. Beginning January 1, 2018, three new codes were introduced (00811, 00812, and 00813), to replace the now deleted code 00810.

Medicare and Commercial payers had different coding rules, which still apply today and impact patients’ financial responsibility through deductibles and/or coinsurance.

procedure, medicare/commercial carrier, medical billing code, base units chart

Since Medicare pays one additional unit for code 00811-PT, it’s crucial that practitioners review their anesthesia records at the end of each case and revise accordingly (i.e., “Screening Colonoscopy converted to Polypectomy”).

Commercial Deductible and Coinsurance amounts may vary by payer.

Medicare Screening Colonoscopy to Polypectomy Patient Cost Sharing Guide

Medicare Screening Colonoscopy to Polypectomy Patient Cost Sharing Guide

The Importance of Proper Coding

Appending the -PT modifier is crucial for accurate Medicare cost sharing purposes. Failure to do so on “Screening to Polypectomy” cases will result in Medicare beneficiaries receiving an erroneous bill, since they should have been granted financial relief on their coinsurance and deductible amounts. An easy way to audit this is to identify 10 case examples and ask for a screenshot from your biller on how they were coded. If you don’t see the -PT modifier appended, your biller will have a big project on their hands and patient refunds to process.

Commercial Payers and Billing Nuances

For Commercial payers, if a case starts as a screening, it’s typically billed with code 00812, regardless of what else is done. However, as is common in medical billing, that’s not representative of all insurance plans. Some want code 00811-PT, just like Medicare. Bottom line: Make sure that your coders have decision trees for all major payers, to avoid denials and promote accurate billing.

There’s one final misunderstood nuance of this service line that involves combined upper and lower GI procedures (EGD + Colonoscopy). These cases have always been subject to standard patient deductible and coinsurance amounts, even if the lower GI procedure is a screening. Unfortunately, many GI endoscopists are unaware of this detail and may advise patients that they won’t receive a bill. That’s simply not the case; the patient will have a balance for both the surgical procedure and the anesthetic, subject to deductible and coinsurance.

Conclusion: Steps to Ensure Accurate Billing

To assess your practice’s GI coding accuracy, we recommend an annual audit by a reputable firm specializing in Anesthesia billing. They’ll look for proper modifier application as well as Screenings that were incorrectly charted and billed without reviewing the endoscopist’s operative report (recommended process). This necessary exercise will help promote accurate billing, reduce inflated Medicare patient coinsurance amounts, and potentially increase insurance collections for this service line.

Hal Nelson, Vice President Anesthesiology Services


VP of Anesthesiology Services

Hal has 30+ years of experience on both the payor and RCM side, with a focus in Anesthesia. He formerly worked as a senior claims approver at United Healthcare, as well as a compliance officer for multiple national anesthesia billing companies. His broad-based experience ensures that MSN clients have a resource for documentation and billing issues. His past speaking engagements include ASA, MGMA, Dartmouth, and Johns Hopkins.

All rights reserved. No part of this document may be reproduced or used in any manner without the written consent of MSN Healthcare Solutions, LLC.

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