The hidden costs of 'free' preventive care: when medical coding meets patient reality.

As a clinician and executive who has spent decades navigating healthcare delivery, I never expected to find myself on the other side of a billing error that captures so much of what is wrong with the system. Yet there I sat, staring at a $1,500 bill for what should have been a fully covered preventive colonoscopy under the Affordable Care Act.

Two years later, and many nights wondering how many others have been through the same thing, it is past time to give back, and the timing could not be more critical. A landmark study published in The Lancet Oncology in January 2024 revealed a troubling global surge in colorectal cancer, with cases expected to rise 31.5% by 2030. The increase is most pronounced among younger adults, with a 90% rise in diagnoses among people under 50 between 1990 and 2019. Alarming, to say the least.

This shifting epidemiology has already prompted major changes in screening guidelines. The U.S. Preventive Services Task Force, whose recommendations directly inform ACA coverage requirements, lowered its recommended screening age from 50 to 45 in 2021. Some other guidelines go further for high-risk individuals, recommending screening colonoscopy starting at age 40, or ten years younger than the earliest diagnosis in the family, whichever comes first, repeated every five years. These evidence-based guidelines form the foundation of preventive care coverage under the ACA, which makes it even more important that billing practices keep pace with our expanding understanding of who needs screening and when.

Colorectal cancer screening guidelines summary

Table 1. Average-risk colorectal cancer screening recommendations.

Screening method	Starting age	Frequency	Endorsing organizations
Colonoscopy	45	Every 10 years	AAFP, ACG, ACS, ASCRS, USMSTF, USPSTF
FIT	45	Annual	AAFP, ACG, ACS, ASCRS, USMSTF, USPSTF
Flexible sigmoidoscopy	45	Every 5 years	AAFP, ACG, ACS, ASCRS, USMSTF, USPSTF
CT colonography	45	Every 5 years	AAFP, ACG, ACS, ASCRS, USMSTF, USPSTF
Stool DNA (Cologuard)	45	Every 3 years	AAFP, ACG, ACS, ASCRS, USMSTF, USPSTF

Table 2. High-risk colorectal cancer screening recommendations.

Risk category	Start age	Frequency	Supporting organizations	Notes
First-degree relative with CRC at age <60	40, or 10 years before the youngest familial case	Every 5 years	ACS, ASCRS, ACG, USMSTF	Colonoscopy preferred
First-degree relative with CRC at age ≥60	40	Every 10 years	ACS, ASCRS, ACG	Colonoscopy preferred
Multiple first-degree relatives with CRC	40, or 10 years before the youngest case	Every 3 to 5 years	ACS, ASCRS, ACG, USMSTF	Colonoscopy required
Lynch syndrome	20 to 25	Every 1 to 2 years	AAFP, ACG, ACS, ASCRS, USMSTF, USPSTF	Colonoscopy required
FAP	10 to 12	Annual	AAFP, ACG, ACS, ASCRS, USMSTF, USPSTF	Colonoscopy required
Personal history, low-risk polyps	5 to 10 years after baseline	Based on findings	USMSTF, ACG	Follow colonoscopy results
Personal history, high-risk polyps	3 years after baseline	Based on findings	USMSTF, ACG	Three or more adenomas or advanced features
IBD (UC or CD)	8 years after disease onset	Every 1 to 2 years	ACG, ASCRS	More frequent if PSC present

Like many patients, I followed my doctor's recommendation for early screening. At 44, I underwent a screening colonoscopy because of my family history of colorectal cancer. My father had multiple polyps removed before age 50, and my paternal grandmother died from the disease. During what should have been a routine screening, the gastroenterologist found and removed two precancerous polyps. As someone who understands provider operations, revenue cycle management, payer services, and health policy, I thought I knew what to expect. Instead, I found myself caught in a maze of coding complexities and misaligned incentives that routinely undermine the ACA's promise of free preventive care.

From personal challenge to systemic insight

My case illustrates both the problem and a path to resolution. After the colonoscopy at Allegheny Health Network, I received a $1,500 bill when my insurer, Blue Shield of California, processed the procedure as diagnostic rather than preventive, based on how the claim was submitted by my provider. Despite meeting every criterion for preventive screening, including my age, a first-degree relative with polyps before 50, and a family history of colorectal cancer, the removal of two precancerous polyps had seemingly reclassified the entire procedure.

What followed was a journey through the labyrinth of healthcare billing that tested even my background in payer operations, provider systems, and policy. After multiple exchanges with both the health system and the insurer, it initially seemed I was at an impasse.

When the health system's billing team cited WebMD as its source for clinical and coding guidance, I knew more authoritative sources were needed. I pointed them to the American Gastroenterological Association's official colorectal cancer screening coding guide, specifying exactly how my procedure should have been coded. CPT 45384 or 45385 with modifier 33 to indicate a preventive service, diagnosis codes Z12.11 and Z12.12 for the screening, Z80.0 and Z83.71 for family history of polyps and neoplasm, plus any additional diagnosis codes applicable to the pathology, such as D12.0, D12.4, and D12.8.

Crucially, I also cited official HHS guidance from the ACA Implementation FAQs, Question 5, which states plainly:

The plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure.

That combination of technical coding knowledge and policy understanding proved decisive. Through persistent advocacy and clear communication about the ACA's preventive care requirements, Blue Shield of California worked to remedy the claim submission errors with my provider and eventually agreed to cover the claim in full.

This resolution, while positive, raises a troubling question. What happens to patients without insider knowledge of the system? A January 2024 NPR investigation by Samantha Liss and Zach Dyer showed this is not an isolated incident, documenting cases where patients faced unexpected charges, from $600 surgical tray fees to full procedure costs, for supposedly free preventive care.

The technical reality behind billing failures

Having led healthcare transformation initiatives, I have seen how well-intentioned policies falter in implementation. The current coding and billing infrastructure was not designed for the nuanced requirements of modern preventive care. When my gastroenterologist found and removed two precancerous polyps during a screening, it triggered a cascade of coding decisions that reflect this misalignment.

The complexity begins with the guidelines themselves. The USPSTF recommends several screening strategies, each requiring different coding approaches, which then drive payer policy. The American Cancer Society adds complexity by recognizing that some patients need earlier screening based on additional risk factors, alongside guidelines from other professional organizations.

This is where the system lags in getting evidence into practice. It requires adoption from clinicians, alignment of payer medical and benefits policies, and provider operations, clinical documentation, and billing processes sophisticated enough to handle this variety while preserving the preventive nature of the service. Medical coding sits at the intersection of clinical documentation, billing practices, and insurance policy. The NPR investigation revealed how facilities have begun unbundling basic supplies from procedure costs, creating new revenue streams that bypass ACA protections.

Elizabeth Mellon, a Michigan teacher billed $600 for a surgical tray, captured the absurdity.

I thought preventive procedures were supposed to be covered at 100%.

Elizabeth Mellon, via NPR

The problem goes beyond simple coding errors. Our system struggles to handle procedures that begin as preventive but evolve into therapeutic interventions. Our billing infrastructure has not kept pace with our understanding of preventive medicine and value-based care, and it lags far behind the billing and financial capabilities of other industries.

Innovation opportunities, reimagining healthcare billing

I see these challenges as opportunities for change, addressing both immediate pain points and the underlying systemic issues.

Digital infrastructure modernization. Modern healthcare requires billing systems that can handle nuanced clinical scenarios, systems that maintain the preventive classification of a procedure while accurately documenting therapeutic interventions. This is not just about better coding. It is about digital infrastructure that aligns with clinical and policy goals and supports clinicians. It also means building systems on authoritative sources maintained against evolving evidence and official guidance, not general healthcare websites. When billing teams can easily access and apply official guidelines from bodies like the AGA and HHS, errors fall and surprises shrink.

Value-based billing alignment. The surgical tray billing issue shows how fee-for-service thinking undermines preventive care. We need payment models that bundle appropriate supplies and services into preventive procedures, removing the incentive to unbundle charges. Some forward-thinking health systems are already doing this, proving it is possible to align financial sustainability with patient-centered care.

Automated compliance and verification. Healthcare organizations need better tools to verify preventive service coverage and catch potential billing errors before they reach patients. Machine learning and natural language processing could flag coding patterns that frequently lead to inappropriate bills, enabling proactive corrections.

Transforming promise into practice

This experience strengthened my conviction that we must do better. The ACA's promise of free preventive care is a crucial step toward a more proactive, equitable system. Delivering on it requires us to reimagine healthcare operations and billing. To shift from hindsight to foresight, I am left with fewer answers than questions.

• Is there a path for patients to input risk factors that can be reduced to appropriate codes, such as Z-codes, which have poor industry adoption today?
• Which provider documents the information that is commonly missed, the ordering provider or the performing provider? That should inform where education is focused.
• How many screening colonoscopies each year produce these surprise bills that push patients into financial hardship?
• How can digital health platforms automate the capture and translation of patient risk factors into appropriate coding, reducing the manual documentation burden?
• What role should EHR vendors play in creating standardized workflows that ensure proper documentation of preventive intent across ordering and performing providers?
• Can claims data reveal the true scope and financial burden of this billing error?

In the meantime, I put together a simple resource that may help avoid these errors by leveraging best practices. It is only a starting point, but it may provide a foundation to prevent the surprises. This is not just about following rules. It is about honoring our commitment to preventive care and maintaining patient confidence in the system.

Colorectal cancer screening, a colonoscopy coding companion guide.

Step	What to do
1. Assess risk level (referring provider)	Review and record risk factors, for example Z80.0 or Z83.7x. Document family and personal history. Verify age appropriateness, 45 or older for standard risk.
2. Confirm screening intent	Confirm preventive-intent documentation. Verify this is a screening rather than a surveillance visit, and note whether it is a first screening or a follow-up.
3a. Determine payer group	Determine whether the payer is Medicare or Commercial and ACA. Check the specific payer policy and coverage requirements.
3b. Referring provider, preparatory documentation	Medicare. Primary diagnosis Z12.11 or Z12.12, secondary as appropriate, intended base code G0121 for average risk or G0105 for high risk. Commercial or ACA. Primary diagnosis Z12.11 or Z12.12, secondary as appropriate, intended base code CPT 45378.
4. Performing provider, document what was done	Medicare. Maintain Z12.11 or Z12.12, assign G0121 or G0105 with CPT 45378 or 45385. If polyps are found, add modifier PT, which flags a screening that converted to diagnostic, though the Part B deductible is not applied. Commercial or ACA. Maintain Z12.11 or Z12.12, assign CPT 45378 for colonoscopy or 45385 with polyp removal. If polyps are found, add modifier 33, which flags a preventive service so the patient is not charged a copay or deductible.
5. Quality documentation	Record all findings clearly. Note polyps or specimens and the removal method, and maintain preventive-intent documentation such as primary diagnosis Z12.11 or Z12.12.
6. Final review and plan	Confirm the primary diagnosis remains Z12.11 or Z12.12, all relevant secondary diagnoses are included such as K63.5 for polyps, modifiers are attached, documentation supports medical necessity, and follow-up intervals are specified.

A path forward, from insight to action

My resolution with Blue Shield shows that proper coverage is possible when all parties understand and correctly apply existing guidelines. But we should not require patients to have insider knowledge or wage prolonged appeals to receive their rightful coverage. The response to NPR's investigation offers some hope. Spectrum Health in Michigan stopped charging separately for surgical trays after being contacted by reporters. But we should not rely on journalism or individual advocacy to drive change.

The stakes are too high for incremental solutions. The Lancet Oncology projection of a 31.5% increase in colorectal cancer cases by 2030 demands urgent action, and cases are rising fastest among those under 50. That makes it even more critical to remove barriers to early screening. As healthcare leaders, we must:

We need a fundamental shift toward simplicity in how we structure, deliver, and bill for preventive care. That means embracing digital innovation, aligning incentives across the ecosystem, and building systems that work for both providers and patients. We have the tools and knowledge to solve this, but the devil is in the details. With colorectal cancer rising worldwide and increasingly affecting younger people, removing barriers is about saving lives. Our patients are counting on us to get this right.

Key references

• US Preventive Services Task Force. Screening for Colorectal Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;325(19):1965-1977.
• Wolf AMD, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018;68(4):250-281.
• Sharma KP, et al. Global trends in incidence and mortality of colorectal cancer by age and country income level, 1990-2019. Lancet Oncol. 2024.
• Liss S, Dyer Z. The colonoscopies were free. But the surgical trays came with $600 price tags. NPR, January 25, 2024.
• American Gastroenterological Association. Coding guide: free colorectal cancer screening. AGA, 2023.

The views expressed here are my own and do not represent the opinions of any current or former employer or affiliated organization. I am not a certified medical coding professional. The coding guidance is based on publicly available resources and should be verified with official coding authorities. Readers should consult certified coding professionals and their organizations for specific coding advice. This article builds on reporting by Samantha Liss and Zach Dyer for NPR and KFF Health News, research in The Lancet Oncology, and guidelines from the USPSTF and American Cancer Society.