Coding help

shadith4

New
Messages
9
Best answers
0
INDICATION: Screening for Colorectal Cancer in a high risk individual with a personal history of colon cancer and ulcerative colitis for many years for surveillance against dysplasia.

PROCEDURE: The procedure and its possible complications which include infection, bleeding and perforation, which may rarely require emergency surgery and may be life threatening, were all explained carefully to the patient. Alternate modalities were reviewed and the fact that a colonoscopy has a recognized miss rate for significant lesions. A digital rectal examination was done first. The scope was introduced in the normal fashion through the anus, rectum and up into the colon. On withdrawal, a careful examination of the entire colon was conducted.

FINDINGS:
Digital exam: Normal.
Extent of exam: Up to the cecum where the ileocecal valve and appendicular orifice were identified.
Quality of Preparation: Good
Difficulty of Intubation: 1 out of 10 (Most difficult is 10)
Terminal Ileum: Normal up to 10 cm
Cecum: Normal, but random biopsies obtained.
Ascending colon: Normal, random biopsies obtained.
Transverse colon: Normal, random biopsies obtained.
Descending colon: Normal, random biopsies obtained.
Sigmoid colon: Starting from 20 cm down to the anus the mucosa was intact but there was loss of vascular markings and a few scars scattered around. There were no ulcers or erosions and only minimal erythema. Multiple biopsies were obtained from the sigmoid and the rectum.
Rectum: This had a similar appearance to the sigmoid above and biopsies were obtained. On retroflexion no other findings.
Operative patient status: The patient tolerated the procedure well.
Postoperative patient status: The patient was observed in recovery and discharged.

FINAL IMPRESSION: Normal colonoscopy except for possible loss of vascular markings in the rectosigmoid region up to 20 cm. Random biopsies obtained.

RECOMMENDATIONS: Await results of biopsies. I advised the patient to continue her current medications since she is in clinical remission. She will call next week for the results of the biopsies. If there was no dysplasia, we will repeat a surveillance in two years.



Background on this patient, she previously had colon cancer 5 years ago, with a history of polyps she had a sigmoidoscopy last year with no problems found.

I coded this

V76.51
V10.05
556.5
v12.72

She called saying that the procedure was coded wrong and should not be a screening.

this is the nurse response

Yes but it also says the pt has a high risk since she personally had colon cancer, so this would exclude screening due to age. They dx would be personal hx colon ca v10.06. I think it is worded poorly, but with my experience I can tell you this would not be a “screening for colon ca due to age v76.51”.

and this is the doctor's

Please note that all our notes due to the template says “screening for colorectal cancer…” but this does not mean that they are just screening. In the eyes of the insurance industry screening is a procedure that is done in an average risk individual who has no symptoms. It states the actual indication which is screening in a high risk patient which in the eyes of the insurance industry is a diagnostic procedure and not average screening. Please do not use the screening codes just because you see the statement “screening for colorectal cancer” make sure you read the rest of the indication to see if there is anything else.

My question is do you believe this was coded right and have you ever heard of an insurance viewing a high risk automatically a diagnostic procedure? I believed if the patient presents with no symptoms its a screening and high risk just indicates the timeline of which the insurance will pay out because its medically necessary. IE Medicare pays every two years for high risk.
 

mitchellde

True Blue
Messages
13,420
Location
Columbia, MO
Best answers
1
biopsies taken in the course of a screening does not make it diagnostic. The difference between diagnositic and screening is intent. A screening is intended for an asymptomatic patient because they meet some predermined criteria such as age OR prior history. A diagnostic exam is due to a patient presenting for sympotmatic reasons or because they have an active disease process that requires diagnostic study, the intent being to use the diagnostic to find what is cuasing the current issue. Because a screening is performed for an asymtomatic patient there is no expectation taht a finding be present. The guideliens tell you that the screening V code is first listed regardless of findings or subsequent procedure like the biopsy being performed. Therefore you have it coded correctly. You can now use the PT or 33 modifier on the 45380 to show it was a screening that became diagnostic.
 

shadith4

New
Messages
9
Best answers
0
I can try to add the modifiers but this was done back in august of 2010 and was BCBS not Medicare. I haven't heard that BCBS is following the new medicare modifiers yet.
 

mitchellde

True Blue
Messages
13,420
Location
Columbia, MO
Best answers
1
Oh I thought this was a 2011 case. therefore you cannot use the modifers for a 2010 case. FYI the 33 modifier is not just for Medicare. If the patient has no screening benefits then that is why she is complaining. Her benefits or lack of is not the issue of the physician office. Your job is code it as it is documented.
 
Top