colonoscopy diagnosis coding

Lindseywingate1990

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i need help with how i should code the diagnosises for this OP report that is a Medicare Claim.


INDICATIONS: the patient is a 65 year old female with a history of crohns colitis, who presents for evaluation by colonoscopy.


PROCEDURE: patient was placed and admenisterd with IV sedation. digital rectal exam performed. colonoscope introduced through the anal canal and easily advanced to the cecum . the ileocecal valve was normal; however on attempts to intubate the ilieum, it was noted to be dramtically inflamed and strictured. multiple biopsies were taken in this area. biopsies were also taken in the right and left colon recrum areas. the right colon appeared to be chronically inflamed where the left colon seemed to be normal.


IMPRESSION: HISTORY OG CROHNS COLITIS WITH MARKED TERMINAL ILEITIS WITH STRICTURING,



WOULD I CODE THIS AS A SCREENING SINCE THEY HAD A HISTORY OF COLITIS AND IT IS NOT KNOWN IF THEY HAVE IT NOW?


v76.51?
558.9?
 
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This can really depend on how your center/doctor words the pre-op information, but to me it sounds like the patient came in for his Crohn's disease (555.0-555.9). It sounds like the patient still is having issues with it and that's what is biospied. I would code this as 45380 with 555.2 (crohn's of large and small intestine) but you should also base the final dx off of the pathology report. If the patient hasn't had a colonoscopy within the last 2 years Medicare does cover a screening, but I'm assuming based off the info given that the patient came in due to their Crohn's.

Bob
 

coachlang3

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I agree with Bob. Sounds like the doctor was doing a crohns surveillance diagnostic procedure.

45380-555.2 and 560.9 (for the stricture)
 

coachlang3

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I would add the PT modifier to 45380 since Crohn's disease is considered a high risk reason to do a colonoscopy every two years.
I wouldn't do that though. It doesn't mention anywhere about screening, high risk or otherwise. It say hx of crohns with evaluation by colonoscopy. To me that says we are doing an evaluation of the current state of the crohn's which would be a diagnsotic right off the bat. The PT is for use in the case of a procedure starting as a screening and then converting to a diagnostic.
 

scorrado

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Having Crohn's disease is considered by Medicare a high risk condition that allows a colonoscopy to be coded as screening. Per guidelines having inflammatory bowel disease, including Crohn's disease and ulcerative colitis allows you to code as a high risk screening. There is also a list of acceptable diagnosis codes that qualify as high risk and 555.2 is on the high risk list. That is why I would use the PT modifier.
 

plynn

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I agree with Bob and Coach .... the report does not indicate anywhere that this was a "screening" so I would not apply the PT modifier.
 

coachlang3

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I know Crohn's is considered a high risk factor but no where does it state screening or even high risk surveillance, The doctor states the pt has a history of crohns and is doing an evaluation via colonoscopy. They are not doing a screening they are evaluating. Which says to me they are looking at the crohn's not to screen if the patient has a malignant neoplasm which is the definition of the colon cancer screen.

Now if the original poster comes back and says in the OV note from the previous visit their doctor's plan was to do a CCS based on history of crohn's, then I would say yes, put the PT on and have the doctor amend their OP note.
 

DeeCPC

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I agree that this would not be a screening.

The screening benefit is for colorectal cancer so the doctor must be clear that s/he is performing a screening to evaluate for colorectal cancer on an asymptomatic patient.

Keep in mind that there is no cure for Crohn's so there is no 'history' of Crohn's disease. Mentioning Crohn's as part of the indications is why this does not seem like the intent is colon cancer screening but continuing evaluation of Crohn's.

'INDICATIONS: the patient is a 65 year old female with a history of crohns colitis, who presents for evaluation by colonoscopy'
 
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