Colonoscopy coding

mrsseeling

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I am a physician coder, we are having conflicting information between the physician coders and hospital (RHIT) coders. Here are some of the questions/discussions we are having....it would be appreciated if any answers have information/articles to back them up. Thank you in advance.
We are in Ohio, CGS Medicare.

1. Screening colonoscopy advanced to the sigmoid colon but not beyond. Would this be coded as 45378-53 or 45330? There seems to be confusion when reading the guidelines in the CPT book. It states that diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 or 44388 with modifier 53 and provide appropriate documentation. However, the colonoscopy decision tree says diagnostic procedure-does not reach splenic flexure-45330.
2. patient with occasional constipation, physician states and codes this as a screening colonoscopy (G0121 Z12.11). Since this is occasional is this still a screening?
3. Reason for appointment is diarrhea. HPI states...patient presents for colonoscopy consult. ROS states...Diarrhea: admits. MDM states...screening colonoscopy Z12.11. Would this be a screening or diagnostic? Do you use the ROS information when determining if a colonoscopy is diagnostic or screening?
4. patient with history of colon cancer. We coded this as G0105 and the hospital coders state that since the physician does not state "screening/surveillance" colonoscopy that it should be coded as 45378 diagnostic. Does the physician have to state "screening colonoscopy" or "surveillance colonoscopy" when they dictate the colonoscopy? The LCD for our state says that a patient with a history of colon cancer should be coded as G0105 Z08 Z85.038
5. our physicians use the office visit note from when the colonoscopy was scheduled as the H&P for the colonoscopy, what information do you use for the H&P and orders for the colonoscopy?
 

nickelclaw

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I have coding both sides of these for Indiana

1. 44388 is only for a stoma.
Yes go by the decision tree. If unable to reach the splenic then it would be a 45330-53 for Medicare profee but facility would use modifier 73 or 74 also use mod 52 for all other insurers(profee). If it goes past splenic but unable to advance to cecum then it would be a 45378 not a screening G code with mod 53 for profee and 73 or 74 for facility. Attached is CMS processing on this see page 5 number 2
https://www.cms.gov/Regulations-and-Guidance/.../r52cp.pdf
https://www.cms.gov/Regulations-and-Guidance/.../R3368cp.pdf This one is the newest update about the mod 53 that is from this year.

2. If doctor states occasional but doesn't see this as an issue and patient has never had a screening. You can code as a screening. Normally the docs I code for will put in a conclusion paragraph below the H/P DX's that constipation or diarrhea or whatever symptom is not the cause for the colonoscopy. That covers him.

3. I do review the ROS on the H/P I would code as a diagnostic or query doc. Again doc must state that diarrhea is not the reason for the screening but could've been reason for office visit. Just don't lead doc to say that.

4. yes history of colon cancer is a high risk screening. Doctor doesn't need to specify as screening or surveillance unless this is your facilities HIM rules.
I have a Medicare Colonoscopy flow sheet if you would like give me an email address. It is older with I9 codes but does show that if patient isn't having symptoms and is a high risk that it goes to a screening. I would use primary code as Z12.11 along with the high risk code as secondary.

5. I review the reason for visit, ROS, history and conclusion of visit. No order needed less it is for clinic lab coder.

Thanks hopes this helps:)
 
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