"Screening EGD"

[ngastroent]

We just received a referral to see a patient for a "screening EGD." I looked through the notes and the primary wants the EGD due to a long history of alcohol abuse. I get where she's going with varices but he doesn't have cirrhosis as of yet. Will an insurance pay when there are no actual symptoms? I've never had this come up before and wasn't finding much with earlier posts

 

[Pam Warren]

As a coder, your job is to code accurately based on the physician's indications and orders, not to code only that which will get paid. You can educate them later about screening vs. diagnostic, but don't compromise your ethics by coding only for payment.

Based on what documentation that you've shared, is the patient currently using ETOH? Then code alcohol abuse. If they're in remission, code it that way. A screening is only appropriate if there are no symptoms that the doctor provided as an indication for the EGD.

Best answer I could give you today is to not look for coverage guidance here on the forums. Everyone's an expert, but unless they provide specific regulatory guidance, you're getting nothing but an opinion. Check Medicare and the commercial payers for their coverage indications for EGDs. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=33583&ver=21

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57063&ver=29

 

[ngastroent]

As a coder, your job is to code accurately based on the physician's indications and orders, not to code only that which will get paid. You can educate them later about screening vs. diagnostic, but don't compromise your ethics by coding only for payment.

Based on what documentation that you've shared, is the patient currently using ETOH? Then code alcohol abuse. If they're in remission, code it that way. A screening is only appropriate if there are no symptoms that the doctor provided as an indication for the EGD.

Best answer I could give you today is to not look for coverage guidance here on the forums. Everyone's an expert, but unless they provide specific regulatory guidance, you're getting nothing but an opinion. Check Medicare and the commercial payers for their coverage indications for EGDs. https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdId=33583&ver=21

https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=57063&ver=29

Thank you for the input. Being a small one doctor office we often do check first so we can educate the patient if the procedure is appropriate coinciding with the diagnosis or referral reason. Appreciate your help