Gastroenterology Coding Alert

Question: A patient was referred to us for a follow-up colonoscopy because his internist performed a screening flexible sigmoidoscopy and thought there was a polyp. Our gastroenterologist performed the colonoscopy, but did not find a polyp. Which procedure code should we use to report the colonoscopy (screening or diagnostic)? Also, which diagnosis code should we use? Our first thought was to use 211.3 (benign neoplasm of other parts of digestive system, colon) as a diagnosis, but we are not sure that is correct.

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Answer: This was a diagnostic colonoscopy performed as a follow-up to a screening flexible sigmoidoscopy and should be reported with 45378 (colonscopy). A screening colonoscopy is one done without the presence of signs or symptoms. When this patient was referred to your practice, his internist suspected, but had not confirmed, that there was a polyp.
 
Determining the correct diagnosis code is a little bit trickier. You cannot report 211.3 because there wasnt a polyp. That diagnosis code can only be used when it has been determined by the pathology lab that there was a polyp, and it was benign.
 
Code 793.4 (nonspecific abnormal findings on radiological and other examination of body structure, gastrointestinal tract) is probably the most appropriate diagnosis. The definition of this code is often abbreviated with the phrase other examinations of body structure left out, so many gastroenterologists incorrectly believe that it only applies to findings on radiological examinations. However, this code should cover the suspected finding by the internist during the flexible sigmoidoscopy.