Revenue Cycle Insider

Question: I read the Revenue Cycle Insider article, “Check out These 7 Steps to Coding Colonoscopies After Positive Fecal Results,” and was wondering if you could help me with a colonoscopy case that entered my workflow:

A patient presented with rectal bleeding and also recently received a positive fecal immunochemical test (FIT) result. The patient came in for a colonoscopy. The physician documented that the primary reason for performing the colonoscopy was to evaluate the patient’s rectal bleeding rather than to complete a screening examination.

How would we report this encounter?

Kansas Subscriber

Answer: Report the appropriate CPT^® code based on the service performed. For example, if the physician performs a diagnostic colonoscopy without biopsy or other intervention, report 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)). If the physician performs a biopsy or polypectomy, report the code that accurately describes that service, such as 45380 (… with biopsy, single or multiple) or 45385 (… with removal of tumor(s), polyp(s), or other lesion(s) by snare technique).

Because the physician performed the procedure to evaluate the patient’s symptoms, the colonoscopy is generally considered diagnostic rather than screening. Do not append preventive modifiers unless payer guidance specifically indicates otherwise.

Sequence the diagnosis code for the patient’s presenting symptom, such as K62.5 (Hemorrhage of anus and rectum), as the primary diagnosis, followed by any additional findings identified during the examination, according to the physician’s documentation and the payer’s coding requirements. Although the patient had a positive FIT result, the presence of symptoms changes the primary intent of the colonoscopy from preventive screening to diagnostic evaluation.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor