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What’s the difference between a screening and a diagnostic colonoscopy?

Screening colonoscopies and diagnostic colonoscopies are performed using the same equipment. The difference is how the procedure is billed to your insurance. Billing will depend on your symptoms (or lack of symptoms) and what your doctor finds during the procedure.

A colonoscopy is considered a preventive screening if the patient doesn’t have any gastrointestinal symptoms and no polyps or masses are found during the colonoscopy.

The Affordable Care Act (ACA) considers preventive services “essential health benefits” and requires insurance companies to pay all associated costs. That also means you won’t have to pay a copay or coinsurance for a screening colonoscopy.

Since a diagnostic colonoscopy isn’t considered preventive, your insurance may require you to pay a copay or coinsurance.

Screening Colonoscopy

A colonoscopy is considered screening when:

  • You’ve had no lower gastrointestinal signs or symptoms before the colonoscopy
  • No polyps or masses are found during the colonoscopy
  • There’s no family history of polyps or colon cancer
  • You have no history of polyps or colon cancer

Diagnostic Colonoscopy

A colonoscopy is considered diagnostic when you’ve had:

  • Signs or symptoms in the lower gastrointestinal tract noted in your medical record before the procedure, including:

    • Abdominal pain that doesn’t improve
    • Anemia
    • Change in bowel habits
    • Constipation
    • Diarrhea
    • Rectal bleeding
    • Blood in the stool
  • Polyps within the past 10 years
  • Abdominal pain that doesn’t improve
  • A positive stool-based test or CT colonography and require a follow-up colonoscopy

Can Screening Become Diagnostic?

It’s true that you may go in for a screening colonoscopy and come out with a diagnostic colonoscopy. If your doctor finds a mass needing biopsy or finds a polyp, your colonoscopy is considered diagnostic at that point. That’s why it’s essential to understand your insurance coverage before your procedure.

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