45380 Colonoscopy w/HX of Crohn's

coderguy1939

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Patient has a 25 year history of Crohn's disease, is clinically asymptomatic maintained by use of long-term medications. The patient came in for a surveillance colonscopy and there was no evidence of Crohn's. Since the patient is still on treatment can this be coded as Crohn's disease even though the entire colon is "grossly normal"?
 

mkj2486

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I would definitely code the Crohn's especially if they are still on treatment. The same is true for cancer. If they are still being treated or even up to a year after you code it as a current condition. It is not considered a "history of" until they have been free of disease for a year. I would think the same is true with Crohn's. My opinion, anyway.
 

scorrado

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Was the patient referred to your office for a "screening"? Does your doctor say anything on the op note about doing the colonoscopy for Crohn's? I would go by what the doctor states is the reason for the colonoscopy on the op note. More than likely it will state Crohn's but you have to go by what is documented.
 

KimmHall

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I would certainly check the documentation and code the Crohns if that is what is stated. Based on most clinical guideline coverages you will not find another dx for the patient, in this case, that supports the 45380. I would also code the long term med use as a secondary to further substantiate the need (for the bx) and as an explanation for the patient being asymptamatic if the insurance company asks you to provide further documentation ( this should be stated by the physician in the op note).
 

coderguy1939

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The doctor states that the colonoscopy is being done as surveillance for a patient with a 25 year history of Crohn's who is asymptomatic and still on meds for Crohn's. He does not state how long the patient has been asymptomatic, but his final DX is "grossly normal colon".
 

Treetoad

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From what I'm reading in your post, I would charge it as screening with the additional dx of crohn's disease. Even though the patient is asymptomatic, it's obvious the provider is still following up on the issue.
 

coderguy1939

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I don't think it can be coded as a screening because of the patient's history. I believe he's doing the biopsy to determine if there are traces of microscopic colitis.
 

KimmHall

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Check your pathology report and see if there are in fact traces of colitis. I also think that you can still code the Crohns disease. While the physician states the pt has a 25 year hx and is asymptomatic, the patient is still being actively treated for the disease with medication, the procedure is being done for surveillance of the progression or recession of the disease while on the medications.


I hope this helps.:eek:
 

Lisa Bledsoe

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Patient has a 25 year history of Crohn's disease, is clinically asymptomatic maintained by use of long-term medications. The patient came in for a surveillance colonscopy and there was no evidence of Crohn's. Since the patient is still on treatment can this be coded as Crohn's disease even though the entire colon is "grossly normal"?
If the intention of the scope was to screen, then V76.51 is dx #1, 555.9 #2. Code 45380 dx2, dx1. You want to list screening as the original intent of the procedure, but bxs were done for crohn's, so you have to link that as the first code on the line item.
 

coderguy1939

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The doctor is doing surveillance to determine the status of patient's Crohn's disease, not screening for neoplasms. So, what I'm getting is that the Crohn's can be coded even if he state preoperatively that the patient is asymptomatic and the final DX is "grossly normal colon".
 

Lisa Bledsoe

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The doctor is doing surveillance to determine the status of patient's Crohn's disease, not screening for neoplasms. So, what I'm getting is that the Crohn's can be coded even if he state preoperatively that the patient is asymptomatic and the final DX is "grossly normal colon".
I say absolutely. The patient is obviously asymptomatic because of medical intervention.
 
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