Prep Colonos

Karl Johnson
5220 Interlachen Blvd

Apt 4
Edina, MN 55436-1453
Your visit to MNGI Digestive Health is coming soon and we are looking forward to seeing you! This friendly reminder and
pre-appointment checklist will help ensure your visit goes smoothly and meets your expectations. At MNGI Digestive
Health, our goal is to provide you with a great patient experience and to deliver genuine, professional care to every
patient.
Please complete all the steps in advance of your visit. If you have any questions about the items listed below, please give
us a call. We can be reached at 612-871-1145 or visit our website at www.mngi.com for more information.
COMPLETE THE FOLLOWING CHECKLIST BEFORE YOUR PROCEDURE

 If you develop COVID-19, are exposed to COVID-19 or have COVID-19 like symptoms at any point after you
schedule your appointment, please call our office to determine if it is okay to proceed with your visit.
 Contact your insurance company regarding coverage
 Is MNGI Digestive Health and the Ambulatory Surgery Center considered in-network? (please carefully read
our financial policy included in this packet for more details to discuss with your insurance company)
 Bring your insurance card and a photo ID to your appointment
 Review your prep instructions (included in this packet)
 Purchase the prep supplies for your procedure if you are having a colonoscopy (a MNGI Prep Kit can be
purchased online at www.mngi.com or at one of our MNGI endoscopy centers. Otherwise, you can purchase as
separate items at your pharmacy)
 Contact your insurance company to verify benefits for both a screening and diagnostic procedure (see the
document in this packet for a description of screening vs diagnostic colonoscopy)
 Arrange a driver for your procedure
Thank you for choosing MNGI Digestive Health.

If you have any questions or need to reschedule your appointment, please call 612-871-1145.
You can also visit our website at www.mngi.com for more information including forms and documents or our FAQs page
at https://www.mngi.com/your-visit/faqs.
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Karl Kordahl Johnson DOB: 01/06/1990 DOS: 06/22/2023 08:30 AM
Printed: 06/22/2023 08:37 AM page: www.mngi.com
Colonoscopy with Miralax Gatorade Split Prep English
Thank you for choosing MNGI Digestive Health. You are scheduled for the following service(s):
Procedure: Colonoscopy
Date: 06/28/2023
Arrival Time: 01:15 PM
Procedure Time: 02:00 PM
Provider: Roberson MD, Erica
Location: Bloomington MNGI Endoscopy Center
5705 W Old Shakopee Rd Ste 150
Bloomington, MN 55437
Purchase the following supplies at your local pharmacy.
2 - Bisacodyl tablets
(Dulcolax® laxative NOT Dulcolax® stool softener) each tablet contains 5 mg of bisacodyl
2 - 8.3 ounce bottle of Polyethylene Glycol (PEG) 3350 Powder

(MiraLAX, SmoothLAX, ClearLAX or generic equivalent)
80 oz. Gatorade®/Powerade® (No red colored flavors)

Regular Gatorade®, Gatorade G2®, Powerade®, Powerade Zero®, Pedialyte or Propel®, Liquid IV, and
other electrolyte beverages are acceptable. Red flavors are not allowed; all other colors (yellow, green,
orange, purple, blue) are okay.
PREPARATION FOR COLONOSCOPY - For your safety, STOP consuming all liquids and nothing by mouth 3 hours prior to your
procedure or your procedure will be cancelled and rescheduled. Please follow detailed instructions below.
Cancel or Reschedule Your Appointment:

If you develop COVID-19, are exposed to COVID-19 or have COVID-19 like symptoms at any point after you schedule this
appointment, please call our office to determine if it is okay to proceed with your visit. COVID-19 guidelines for health care
facilities may differ from community guidelines. In addition, if you are having flu-like symptoms (such as fever, cough, shortness
of breath) within 14 days of your appointment, please call to reschedule. If you have any newly diagnosed medical condition
(like diverticulitis, heart problems, breathing problems), please call our office. If you need to cancel or reschedule for any other
reason, call 612-871-1145 at least 72 hours prior to your appointment.
Transportation:
You must arrange for a responsible person to escort you to your procedure. A taxi ride is not an option unless you are
accompanied by a responsible person. If you fail to arrange transportation with a responsible person, your procedure
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will be canceled and rescheduled. Depending on COVID-19 transmission, your driver may or may not be able to join
before and after the procedure.
7 days before:
 Discontinue fiber supplements and medications containing iron. This includes multivitamins with iron,
Metamucil and Fibercon.
 Confirm a driver for your procedure.
3 days before:
 Begin a Low-Fiber Diet. A low fiber diet helps make the cleanout more effective.
 Examples of a low fiber diet include (but are not limited to): white bread, white rice, pasta, crackers,
fish, chicken, eggs, ground beef, creamy peanut butter, cooked/boiled vegetables, canned fruit,
bananas, melons, milk, plain yogurt, cheese, salad dressing and other condiments.
If you are on a gluten free diet, look for items with less than 2 grams of fiber per serving including
bread, pasta, waffles, pancakes, cold cereals, rice cakes, rice crackers, and cream of rice.
 The following are not allowed on a low fiber diet: seeds, nuts, popcorn, bran, whole wheat, corn,
quinoa, raw fruits and vegetables, berries and dried fruit, beans and lentils.
For additional details on following a low fiber diet, please see www.mngi.com/conditions/low-fiber-diet
2 days before:
• Continue Low Fiber Diet.
• Drink at least 8 glasses of water throughout the day.
• Stop eating solid foods at 11:45 pm.
1 day before:
 Begin Clear Liquid Diet (clear liquids include things you can see through).
 Examples of a clear liquid diet include: water, clear broth or bouillon (gluten free options
available), Gatorade, Pedialyte or Powerade, carbonated and non-carbonated soft drinks (Sprite,
7-Up, Gingerale), strained fruit juices without pulp (apple, white grape, white cranberry), Jell-O,
popsicles, and up to one cup of black coffee or tea (no milk or cream) each day.
 The following are not allowed on a clear liquid diet: red liquids, alcoholic beverages, dairy
products, protein shakes, cream broths, juice with pulp, products containing oil and chewing
tobacco.
 For additional details on following a clear liquid diet, please see

https://www.mngi.com/conditions/clear-liquid-diet
 At noon: Take 2 Bisacodyl (Dulcolax) tablets

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• Between 4-6pm: Drink Miralax – Gatorade/Powerade preparation.
 Mix 1 bottle of Miralax with 64 oz. of liquid (a minimum of 56 oz of electrolyte beverage should
be used to mix Miralax and up to 8 oz of water can be added to achieve the desired 64 oz).
 Drink 1 – 8 oz. glass of the Miralax/electrolyte solution.
 Continue drinking 1 - 8 oz. glass every 15 minutes thereafter until the mixture is gone.
Colon Cleansing Tips: Drink adequate amounts of fluid before and after your colon cleansing to prevent dehydration. Stay near a
toilet because you will have diarrhea. Even if you are sitting on the toilet, continue to drink the cleansing solution every 15
minutes. If you feel nauseous or vomit, rinse your mouth with water, take a 15 to 30-minute break and then continue drinking
the solution. You will be uncomfortable until the stool has flushed from your colon (in about 2-4 hours). You may feel chilled.
Day of your procedure:

You may take all of your morning medications including blood pressure medications, blood thinners (if you have not been
instructed to stop these by our office), methadone, anti-seizure medications with sips of water 3 hours prior to your
procedure or earlier. Do not take any chewable vitamins or supplements. If you have diabetes, contact your monitoring
provider for further direction on insulin and/or blood sugar management.
Continue the Clear Liquid Diet up to 3 hours prior to your procedure, then stop drinking. As a reminder, continue to avoid red
liquids, alcoholic beverages, dairy products, protein shakes, cream broths, juice with pulp, products containing oil, chewing
tobacco and illicit drugs. Use of these will result in your procedure being cancelled.
 4 hours prior to your procedure time (Example: 3:30am for a 7:30am procedure):
 Drink Miralax – Gatorade/Powerade preparation (must be completed within one hour)

 Mix 4 capfuls of Miralax with 16 oz. of Gatorade/Powerade in a large pitcher.
 Drink 1 - 8 oz. glass of the Miralax - Gatorade/Powerade solution every 15 minutes thereafter
until the mixture is gone. This should take approximately 30 minutes and must be completed
within 1 hour.
 3 hours prior to your procedure time (Example: 4:30am for a 7:30am procedure)
 STOP consuming all liquids.
 Do not take anything by mouth during this time.
 Allow extra time to travel to your procedure as you may need to stop and use a restroom along
the way.
You are ready for the procedure if you followed all instructions and your stool is no longer formed, but clear or
yellow liquid. If you are unsure whether your colon is clean, please call our office at 612-871-1145 before you
leave for your appointment.
Bring the following to your procedure:

 Insurance Card / Photo ID
 List of Current Medications including over-the-counter medications and supplements
 Bring your rescue inhaler if you currently use one to control asthma
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 Bring contact lens supplies as you will be asked to remove contact lenses prior to the start of your procedure
 Advance Directives: If you have an Advance Directive, please bring a copy of your Advance Directive with you to your
endoscopy appointment. Advance Directives are not honored at MNGI facilities, and in the event of a life-threatening
situation, life support measures will be instituted in every instance and our patients will be transported to a higher level
of care facility (i.e., hospital). In the unlikely event that you require an emergency transfer to a higher level of care
facility, your Advance Directive should accompany you to that facility.
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DESCRIPTION OF COLONOSCOPY
What is colonoscopy?
Colonoscopy is the most accurate test to detect colon polyps and colon cancer, and the only test where polyps can be removed.
During this procedure, a doctor examines the lining of your large intestine and rectum through a flexible tube called a
colonoscope. The colonoscope is inserted into the anus and advanced slowly through the colon.
To produce the best results, you will drink a bowel cleansing preparation to help clean out your colon. Even if your stools are
clear, it is important to take all of the colon prep as directed because your body is always making fluid and small polyps can hide
behind this fluid.
What happens during a colonoscopy?

Plan to spend up to 2 hours at the endoscopy center the day of your colonoscopy. The procedure itself takes about 20 to 40
minutes to complete.
Before the procedure:

Your medical history will be reviewed with you by your health care team including a nurse, your gastroenterology physician and
an anesthesia provider and an IV line will be placed.
During the procedure:

During your procedure the anesthesia provider will administer medications and monitor vital signs which is a process known as
Monitored Anesthesia Care (MAC). While most patients sleep through the procedure, some remain awake and aware. The
anesthesiologist and/or certified registered nurse anesthetist (CRNA) will help determine the appropriate type of drug to be
used during the procedure to keep you safe and comfortable. If abnormal tissue or polyps are found, the physician may remove
them through the colonoscope for closer examination or biopsy.
What happens after the procedure?

The physician will talk with you about the initial results of your procedure and will prepare a full report for the healthcare
provider who referred you for the colonoscopy. You may have some cramping or bloating after the procedure which is
normal and should disappear quickly by passing gas. Any tissue samples or polyps removed during the procedure will be
sent to a lab for evaluation. It may take 5-7 working days for you to be notified of the results by mail or through the Patient
Portal.
You may resume most of your regular activities the day after the procedure. However, medication given during the procedure
will prohibit you from driving for the rest of the day. You are also advised to avoid air travel for 24 hours following your
procedure. You may resume your normal diet, but alcohol should be avoided until the next day after your procedure.
Are there possible complications with colonoscopy?

Although serious complications are rare, any medical procedure has the potential for risks. Risks from the procedure include
perforation, or a tear through the lining of the colon, bleeding from a biopsy site, reaction to medications, heart and lung
problems, and dental or eye injuries.
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Colonoscopy – Screening versus Diagnostic
The Affordable Care Act (ACA) requires private health insurers to cover recommended preventive services without any
patient cost-sharing, such as copays and deductibles. One of those recommended services is screening colonoscopy. This
means if a patient has a screening colonoscopy there should be no out-of-pocket expense. Conversely, if a patient has a
diagnostic colonoscopy, the procedure is nearly always covered by insurance; however the patient is still responsible for any
copays, coinsurance and/or deductibles.
What’s the difference between a screening colonoscopy and a diagnostic colonoscopy?

 A screening colonoscopy is performed on an asymptomatic (no symptoms) patient for the purpose of testing for
colorectal cancer or colon polyps. Whether an abnormality is found does not change the screening intent of the
procedure.
 A diagnostic colonoscopy is performed because of a sign or symptom such as diarrhea, positive hemoccult, rectal
bleeding, iron deficiency anemia, abdominal pain, or an abnormal finding on another test. Medicare and most
commercial payers do not waive the copay and/or deductible if the intent of the procedure is a diagnostic colonoscopy.
This means the patient is responsible for any balance left owing after insurance processes the claim.
I have Medicare – what is my screening benefit?

Medicare covers screening colonoscopy every 10 years* for average risk, asymptomatic patients and every 2 years for high
risk, asymptomatic patients.
Medicare defines high risk as patients with one or more of the following:
 A first-degree relative (sibling, parent, child) who has had colorectal cancer or an adenomatous polyp
 Family history of familial adenomatous polyposis
 Family history of hereditary non-polyposis colorectal cancer
 Personal history of adenomatous polyps
 Personal history of colorectal cancer
 Inflammatory bowel disease, including Crohn’s disease or ulcerative colitis
*Screening colonoscopy is not covered within 47 months of a previous screening sigmoidoscopy
I have commercial/private insurance - where can I find my screening benefits?

You should contact your insurance company directly, using the information on the back of your insurance card. Be ready to
provide your plan numbers. We can assist you with a price quote letter that includes the procedure (CPT) codes your
insurance company may ask for. Be advised we cannot determine prior to your colonoscopy exactly what will be found
during the procedure and the exact CPT codes that will be billed.
Before your procedure, you should know if you are coming for a screening colonoscopy (no symptoms) or a diagnostic
colonoscopy (you are presenting with symptoms). After determining if screening or diagnostic applies, you should do some
research with your insurance company regarding your benefits and any out-of-pocket expenses that may be applied.
Your referring and/or primary care physician may refer you for a “screening” colonoscopy along with some symptoms you
are currently experiencing. There may be a misunderstanding of the word screening. Your colonoscopy procedure is unable
to be billed as a screening procedure if you are experiencing any symptoms. We are required to bill according to the reason
the procedure is ordered.
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The physician cannot change, add or delete any diagnosis so that you can be considered for a screening colonoscopy. Your
visit is documented in the medical record from information you or your referring and/or primary care physician have
provided during the pre-procedure assessment, or during a previously documented clinic visit when the colonoscopy was
ordered. These are binding legal documents that cannot be changed to facilitate better insurance coverage.
Patients need to understand that strict government and insurance company policies, as well as coding guidelines prevent
physicians from altering a chart or bill for the sole purpose of better coverage determination. This is considered insurance
fraud and is punishable by law.
Please contact your insurance company or MNGI with additional questions regarding coverage.
Results from any testing will be sent via mail or the Patient Portal.
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COVID-19 Safety
What is MNGI doing to help keep patients safe during the coronavirus outbreak (also known as COVID-19)?
Patient safety has always been our top priority. MNGI has followed guidance from the Centers for Disease Control (CDC) and
the Minnesota Department of Health and made additional adjustments to patient screening and cleaning processes to ensure
the safest experience possible.
COVID-19 Symptom Screening
MNGI will screen all patients for COVID-19 symptoms as well as screen all staff and visitors upon arrival to any MNGI facility.
MNGI will ask about recent and new symptoms as recommended by the CDC and will take appropriate follow up steps based on
current guidance. The appointment may need to be cancelled on short notice if the patient tests positive for or experiences
symptoms of COVID-19, or if the facility or service area requires additional capacity to address COVID-19. Only staff and
providers who have certified that they are healthy and passed screening will be allowed to work.
Limiting Guests and Social Distancing

In order to keep you and our providers safe, MNGI asks that you follow social distancing and infection prevention guidelines in
our facilities. The clinical spaces have been reconfigured as much as possible to allow for social distancing. We ask that you limit
the number of visitors that accompany you to our clinic.
Masks and Personal Protective Equipment (PPE)

All MNGI staff, providers and vendors who enter the clinical locations will be wearing masks. We also ask that you wear a
surgical mask upon arrival to our facility. Patients and any visitors arriving without masks will be provided a mask and will be
required to wear it for the duration of their visit. Masks with valves are not permitted as these masks do not block exhalation
and are primarily designed for construction sites.
Cleaning and Air Flow
Cleaning efforts have been increased at clinical sites for high touch areas such as door handles, keyboards, phones, counter tops,
bathrooms, waiting room furniture and more. This includes routine cleaning, increased frequency and deep cleaning processes
throughout the facilities. MNGI uses an FDA-approved registered disinfectant that kills coronaviruses. MNGI also has ventilation
systems that help to exchange air at regular intervals.
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FINANCIAL POLICY (Insurance and Billing)
MNGI Website: Visit our website at www.mngi.com to request a price quote, pay online, obtain details of our financial assistance
program and for other important information.
Insurance and Billing Process: It is your responsibility to confirm your insurance benefits with your insurance plan(s) prior to your clinic
visit or procedure. If your insurance plan(s) require(s) a co-payment, the co-payment is due at the time of your appointment. We accept
payment by credit card or check only. We ask that you provide current insurance information and photo identification each time you
check in for an appointment at one of our offices/facilities. Failure to present your current insurance card(s) will release MNGI from any
responsibility for incorrect or untimely filing of contracted claims. Please alert our reception staff of any changes in insurance or personal
information.
Claims Submission: If you have provided us with insurance information, we will submit a claim(s) to your insurance plan(s) and will assist
you in any way we reasonably can to facilitate getting your claims paid. However, your insurance plan(s) may need you to supply certain
information directly and it is your responsibility to comply with this request.
Pre-Authorization and Pre-Certification: If your insurance plan(s) require(s) a pre-authorization or pre-certification, you are responsible
for calling our Business Office at (612) 871-1145, prior to your appointment and our staff will assist you in obtaining approval for your
visit or procedure.
Referrals: If your insurance plan(s) require(s) a referral, you are responsible for obtaining this referral from your primary care provider or
clinic prior to your appointment.
Billing: Once your insurance claims have been processed by your insurance plan(s), a statement will be sent to you for any deductible, co-
insurance, co-payment or other remaining balance not paid by your insurance plan(s). If you are scheduled for a procedure, you will
receive more than one statement. One statement from MNGI Digestive Health P.A. will represent the physician fees and a second
statement from Affiliated Endoscopy Center LLC, MNGI Endoscopy ASC Inc., Minnesota Endoscopy Center LLC, or ambulatory surgery
center or hospital which represents the facility fees. You could also receive separate bills from the pathologist (Hospital Pathology
Associates) if a biopsy of a polyp or tissue sample was needed. If Monitored Anesthesia Care (MAC) is provided by an anesthesiologist
and/or CRNA during your procedure, there will be additional charges billed. If you have a clinic visit or a procedure you could also receive
a bill from the laboratory (LabCorp, Prometheus and/or Quest Diagnostics) if blood work was done. Please check your insurance for
specific benefits.
Payment: Payment in full is due upon receipt of your statement(s). We accept payment by credit card (Visa, MasterCard, American
Express and Discover), personal check, or money order. Payments by credit card and check can be made online at www.mngi.com. If you
are unable to pay your balance in full, it is your responsibility to contact our Business Office to establish a mutually agreeable, interest-
free payment plan and to discuss other financial assistance options which may be available. Failure to pay your balance and/or comply
with any arrangements that have been established may result in the forwarding of your account to a collection agency and may result in
being unable to schedule future appointments at MNGI or its facilities until the full balance has been paid.
Financial Assistance: Providing premier gastrointestinal care is important to us regardless of one’s financial status. We have assistance
options available to accommodate a variety of financial situations. Please contact our Business Office at (612) 871-1145 for information
regarding our Financial Assistance Program.
Our practice is committed to providing the best treatment for our patients. Thank you for choosing MNGI and understanding and
complying with our financial information. If you have any questions or concerns regarding this information, please contact our Business
Office at (612) 871-1145.
Disclosure Statement
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Your healthcare provider is referring you to a facility in which the healthcare provider may have a financial or economic
interest.
MNGI Digestive Health is proud to partner with the following GI practices to provide endoscopy services:
Allina Health Colon & Rectal Surgery Associates

(763)236-9045 (651)225-7979
Voyage Healthcare University of Minnesota Physicians

(763)587-7752 (612)625-5155
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Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you
are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?

When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a co-payment, coinsurance,
and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn't in
your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may
be permitted to bill you for the difference between what your plan agreed to pay, and the full amount charged for a service. This is called
“balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-
pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have
an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:

Emergency services
If you have an emergency medical condition and get emergency services from an out of network provider or facility, the most the
provider or facility may bill you is your plans in network cost-sharing amount (such as co-payments and coinsurance). You can’t be
balance billed for these emergency services. This includes services you may get after you’re in stable condition unless you give written
consent and give up your protections not to be balanced billed for these post-stabilization services.
Certain services at an in-network hospital or ambulatory surgical center

When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In
these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine,
anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t
balance bill you and may not ask you to give up your protections not to be balance billed. If you get other services at these in-network
facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren't required to get care out-of-network. You can
choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
 You are only responsible for paying your share of the cost (like the co-payments, coinsurance, and deductibles that you would pay if
the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
 Your health plan generally must:
 Cover emergency services without requiring you to get approval for services in advance (prior authorization).
 Cover emergency services by out-of-network providers.
 Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show
that amount in your explanation of benefits.
 Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket
limit.
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If you believe you've been wrongly billed, you may contact the Department of Health & Human Services, 1-877-696-6775. Visit
www.hhs.gov for more information about your rights under federal law.
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Karl Johnson

5220 Interlachen Blvd

COMPLETE THE FOLLOWING CHECKLIST BEFORE YOUR PROCEDURE

Thank you for choosing MNGI Digestive Health.

Purchase the following supplies at your local pharmacy.

2 - 8.3 ounce bottle of Polyethylene Glycol (PEG) 3350 Powder

80 oz. Gatorade®/Powerade® (No red colored flavors)

Cancel or Reschedule Your Appointment:

 For additional details on following a clear liquid diet, please see

 At noon: Take 2 Bisacodyl (Dulcolax) tablets

Day of your procedure:

 Drink Miralax – Gatorade/Powerade preparation (must be completed within one hour)

Bring the following to your procedure:

What happens during a colonoscopy?

Before the procedure:

During the procedure:

What happens after the procedure?

Are there possible complications with colonoscopy?

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

I have Medicare – what is my screening benefit?

I have commercial/private insurance - where can I find my screening benefits?

Limiting Guests and Social Distancing

Masks and Personal Protective Equipment (PPE)

Allina Health Colon & Rectal Surgery Associates

Voyage Healthcare University of Minnesota Physicians

What is “balance billing” (sometimes called “surprise billing”)?

You are protected from balance billing for:

Certain services at an in-network hospital or ambulatory surgical center

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