Colonoscopies are a common medical procedure used to examine the large intestine, primarily for detecting and preventing colorectal cancer. They are classified as either screening or diagnostic. Understanding this distinction is important for patients, as it impacts their purpose and potential implications.
Screening and Diagnostic Colonoscopies Defined
A screening colonoscopy is performed on individuals without colorectal symptoms. Its primary purpose is to prevent colorectal cancer by identifying precancerous polyps or early-stage cancer before symptoms develop. For average-risk individuals, screenings are typically recommended starting at age 45 or 50, with subsequent screenings usually advised every 10 years if no abnormalities are found.
In contrast, a diagnostic colonoscopy is conducted when an individual presents with specific gastrointestinal symptoms or has abnormal results from other tests. These symptoms might include rectal bleeding, unexplained abdominal pain, changes in bowel habits, or anemia. The aim of a diagnostic colonoscopy is to investigate the cause of these symptoms, confirm a suspected condition, or follow up on previous findings such as a positive stool test. Unlike screening colonoscopies, diagnostic procedures do not follow a fixed schedule and are performed based on medical necessity.
When a Screening Becomes Diagnostic
A colonoscopy initially intended for screening can be reclassified as diagnostic if certain findings occur. The most common trigger is the detection and removal of a polyp or other suspicious lesion. If a doctor identifies and removes a polyp (polypectomy) or takes a biopsy of abnormal tissue, the procedure’s classification often shifts. This reclassification is primarily for medical coding and billing purposes.
This shift occurs because an intervention, such as tissue removal or biopsy, moves the procedure beyond simple preventative screening. The intent changes from merely looking for abnormalities to actively addressing them. If no abnormalities are found, or if observed abnormalities are not removed or biopsied (e.g., only monitored), the colonoscopy generally retains its original screening classification.
What Happens After Reclassification
When a screening colonoscopy is reclassified as diagnostic, there are practical implications for the patient, particularly concerning insurance coverage. Screening colonoscopies are often covered at 100% under preventive care benefits, as mandated by acts like the Affordable Care Act for many private insurance plans. However, diagnostic procedures may be subject to different financial terms, including co-pays, deductibles, or co-insurance, meaning the patient might incur out-of-pocket costs. While some private insurers may still cover the procedure as screening even with polyp removal, Medicare policies can differ, potentially requiring patients to pay a percentage of the approved amount for the doctor’s services. Patients should clarify their specific insurance benefits before the procedure.
Beyond financial considerations, the reclassification also impacts follow-up care and medical records. The removal of polyps or other abnormalities typically necessitates a pathology review of the tissue to determine its nature, such as whether it is precancerous or cancerous. Depending on these results, the patient may require more frequent surveillance colonoscopies in the future, rather than the standard 10-year interval for average-risk individuals. The reclassification is formally documented in the patient’s medical records, accurately reflecting the nature of the procedure and any findings or interventions. Medical teams typically communicate these changes and their implications to the patient to ensure understanding of the next steps.