Preventative Testing – Unique Risk Stories – Listening to your patients
By Jill Young CEMC, CPC, CEDC, CIMC
September 27, 2024
I am going to tell you a story about my family and their journey with Preventive Testing and colon cancer. Names have been changed to protect the innocent and some facts may have been embellished upon for better story content.
In 2001, my father was diagnosed with colon cancer. That day I went from low risk to high risk in an instant. I needed and wanted to be screened but I was under the 50-year age guidelines, at that time, recommended. Luckily, the insurance I had at the time allowed for screening for a high risk individual UNDER the recommended age, so I could be screened and have coverage. Interestingly, my insurance changed two months later. When I checked, I would not have had coverage for the screening under my new policy. That policy had different standards for coverage. My brother is younger than I and was also lucky to have insurance that covered his preventative testing. He was found to have five polyps. He was 43. If he did not have that colonoscopy testing, at that early age and those polyps found, the doctors said he would probably have died before reaching the age of recommended screening.
My mother in law was diagnosed with colon cancer in 2020. She had a colon resection and did well. She was 88 at the time. At that time, in 2021, the United States Preventive Services Task Force (USPSTF) recommended that “clinicians selectively offer screening for colorectal cancer in adults aged 76 to 85 years”. These are the people who Medicare’s policy follows. She had no personal or family history of colon cancer. I assume that is why she was never screened. Newer studies that the USPSTF are reviewing now show screening after age 75 was linked with a 39% reduction in the incidence of colorectal cancer and a 40% decrease in the risk of death from the disease. She got caught in between changes in the rules.
So it is an evolving process for offices to stay up to date on current USPSTF guidelines. Just as important is noting where Insurances are with changes in their coverages especially with the USPSTF’s and the American Cancer Society’s (ACS) recent lowering of the recommended age for screening to 45 years.
It’s all about the risk, but it also is about the patient. There are still exceptions to be looked at. The ACS states that “people with a history of colorectal cancer in a first-degree relative (parent, sibling, or child) are at increased risk. The risk is even higher ……..if more than one first degree relative is affected.” Sounds good. But let’s look at my daughter who is 35 years old. She has a maternal grandfather AND a paternal grandmother who both had colon resections because of colon cancer. Is she at high risk? The policy states first-degree relative and grandparents are not on the list. Do you think she should she be tested early? Would your provider feel she is high risk?
There are rules and then there are people. Rules sometimes are meant to guide us. As a matter of fact, sometime the rules are called guidance recommendations.
Now to the learning part of this article. First, your office needs to know what “the rules” are for your insurances. Know that there is variability within them, especially around age and who should be considered a first-degree relative. Next, your provider needs to listen to their patients. When we look at phrases like longitudinal care and what it means, documentation in the chart of these conversations shows that relationship. Notations that a patient’s grandmother was just diagnosed with colon cancer and that the provider will be looking at current risk guidelines to see next steps in that patient’s care, shows work. A follow up note in the chart showing what the provider’s plan is for the patient also shows work. Documentation of a phone call to the patient noting points of the discussion about her options for screening shows work. And if there is additional conversation about preventive screening and the patient’s risk during an appointment, documentation of such support that the provider’s care is the continuing focal point for all needed healthcare services for that patient. It can show the ongoing relationship between the patient and the physician that the new complexity codes are about.
One last anecdotal story. When I went to my doctor’s office for my “annual” visit, I asked about AAA screening. I was initially told that it was only available for men age 65-75 who have a smoking history. I explained that both my parents had had surgery for removal of AAA’s. When the doctor and I discussed it, he agreed I should have the screening test. I received a call from the scheduling department indicating that my insurance would not cover the test. I was again told it was only for men. As I politely explained to the scheduler that I had risk from both my parent’s history, she said that the order had not indicated any risk. If what I said was true, then they told me I would have to have the order re-coded and resent. I’m glad I knew the rules!!
Be sure that the rules are known, but also be sure that your provider knows that exceptions to the rules can be made. Yes, it may take a prior authorization to explain to the insurance company the unusual risk of the patient to have a screening test covered, but if the patient has concern and wants to have the screening done, exceptions are worth the effort for peace of mind and good patient care.
About Ms.Young:
Jill founded her company over 20 years ago to help meet the educational and administrative needs of physicians and their practices. An accomplished presenter, auditor and author, her love of coding and billing and especially ICD-10 shows through.
