Wiki Colonoscopy Consult


Spokane, WA
Best answers
We are struggling to educate providers on appropriate level for screenings when there are no symptoms present other than patient age and or history of never having a colonoscopy. We are also questioning whether or not these types of screenings should be billed as everything we've found states the consult is included in the procedure. All of our providers want to code as a level 4 (sometimes 5) due to Exam elements. As coders we cannot see where MDM, HPI or ROS meets the higher levels.
Any insight on appropriate level will be appreciated.

In this example I am getting:

MDM - Straight forward
HPI - 1
ROS - 10
Exam - 10
My suggested level is 99213

Chief Complaint: Colonoscopy Consult

History of Present Illness:
57 Years Old Male who presents today for screening / diagnostic colonoscopy evaluation.
The patient was referred by:
Indication(s): colon cancer screening
Current GI symptoms: none

Previous EGD / Colonoscopy: none
Personal GI History: none
Family History of Colon/GI Disease / Cancer: none

Anesthesia Concerns: none
ASA Class: 2
Bleeding Risks Noted: none

I have explained the colon prep and procedure in detail with the patient and answered all questions. The patient is willing for me to perform their COLONOSCOPY with or without biopsy using conscious sedation. They also agree to the risks as I have explained them which include, but are not limited to, excessive bleeding, pain, infection, adverse anesthesia reaction and/or colonic perforation.

Problem List Changes:
Added new problem of Screening for malignant neoplasm, colon (ICD-V76.51) (ICD10-Z12.11)
Assessed Screening for malignant neoplasm, colon as new

Medication List: (Reviewed and Updated)
Allergy List: (Reviewed and Updated)

Medical History: (Reviewed and Updated)
benign essential hypertension

Social History: (Reviewed and Updated)
Patient is a former smoker.
Alcohol Use - yes
Drug Use - no
HIV/High Risk - no
Regular Exercise - yes

Family History: (Reviewed and Updated)
FH Hypertension
father cardiomyopathy died 67 y/o

Risk Factors:
Tobacco: (Reviewed and Updated)
Tobacco Smoke Status: Former smoker
Tobacco Use? Former
Cigarettes - Packs / Day: 1
Packs per year: 42 Pack years
Cigarettes - Year Started: 1977 Cigarettes - Years Smoked: 42
Cigarettes - Year Quit: 2013
Passive smoke exp: no

Review of Systems:
All other systems reviewed and are negative

General: Denies fever, chills.
Cardio: Denies chest pain, palpitations.
Respiratory: Denies SOB, cough.
GI: Denies vomiting, diarrhea.

Vital Signs:
Weight: 223 lbs. (101.36 Kg.) Height: 69 in. (175.26 cm.) BMI: 33.05
Temperature: 97.9 deg F. (36.6 deg C.) Temperature Site: Temporal
Respiration: 16 O2 Sat: 96 On: Room air Pulse: 77 Pulse Rhythm: Regular
Blood Pressure #1: 118/76 mm Hg. Location: Lt Arm Position: sitting
Entered by:

Physical Exam:
General: Well developed, well groomed, in no acute distress.
Head: Normocephalic/atraumatic.
Eyes: PERRL, EOMI; conjunctiva and sclera clear.
Nose: No deformity/significant septal deviation; Normal mucosa.
Mouth: Mucus membranes moist; No erythema / exudates.
Neck: Supple; No thyromegaly or nodules.
Lungs: Clear to auscultation bilaterally.
Cardio: RRR; Normal S1, S2; Without murmurs, gallops, rub, or click.
Abdomen: Soft/nontender; No guarding or rebound; Bowel sounds present.
Extremity: No cyanosis or edema.
Skin: No rashes or atypical lesions.
Psych: Alert and oriented.

Assessment and Plan:
screening colonoscopy

Medication List Changes:
Added new medication of DULCOLAX 5 MG ORAL TABLET DELAYED RELEASE (BISACODYL) Take 4 tablets as directed; Route: ORAL - Signed

Added new medication of MIRALAX ORAL POWDER (POLYETHYLENE GLYCOL 3350) Use as directed for colonoscopy prep; Route: ORAL - Signed

Est. Level 4: Extensive [CPT-99214]
It is my understanding that a visit before colonoscopy cannot be billed for as it is included in the global fee for the colonoscopy.