Wiki Colonoscopy Diagnostic vs Preventative - What's your Opinion

[AthensCoder]

Hello Everyone,

I wanted to get other's opinions on the much debatable issue of diagnostic versus preventative colonoscopy in my office. I have several providers within my office that like to order "screening" colonoscopies for the below scenarios.

1. Pt says they are here for a screening colon, first colon ever, but in the medical record physician documents symptomatic issues of constipation, rectal bleeding, diarrhea, etc. My provider feels that since the patient has not had a screening colon that they can order the procedure as such. I advise the provider that since the patient presented with symptoms then it is not a screening, per several articles I have found on the web from AAPC. How many other coders/billers have come across this issue and how did you handle this situation?

2. Patient comes in for screening colonoscopy. Provider documents that patient has "stable" chronic constipation. How would you code? In my opinion, patient has an issue and thus would be diagnostic, but the providers states that since it is stable it can be coded as a screening. Opinions?


Thank you all for your thoughts and opinions.

 

[kboyd22]

I have this issue all the time as well. However I explain to the providers that the description/definition of a "screening" service states that the patient must be asymptomatic and asymptomatic means no symptoms and constipation, abdominal pain, diarrhea, blood in stool, etc. are all symptoms. Ours are notorious for "screening colonoscopy-incidental evaluation of blood in stool-hematochezia"

Kim Boyd, CPC

 

[Tine]

The minute the provider states an incidental finding on the op report, it becomes diagnostic. I have had many discussions with auditors and the providers. I come across the same issues of "Screening colonoscopy - incidental diarrhea." Sorry Doc, it is not a diagnostic study due to that symptom of diarrhea. Since I am unable to code off of anything but the report when I do a procedure, I stress to the provider that any and all info that is pertinent needs to go under the indications. Also, we stress to the providers that they do not tell the patient that it will be covered under their preventative services, because not every insurance plan has preventative services. Unfortunately nothing is perfect and some providers insist that since it is their first colonoscopy it is a screening even with symptoms.

1. It would be considered diagnostic because they have symptoms, whether this is their first colonoscopy or not.

2. Just because a symptom is stable does not mean it is not important. It is still a symptom and as such it would be a diagnostic test.

Education is the only way I could see to help rectify these issues. If you feel that your information is falling on deaf ears, it may be time to bring in an auditor or third party. Good Luck.

Christine Medvetz, CPC

 

[AthensCoder]

Hi Christine,

The issue I come into is when the patient comes in for the evaluation the docs states rectal bleeding, diarrhea, etc. BUT on the OP note does not list these symptoms. I've explained several times that the patient MUST be symptom free, i.e, no problems.

The minute the provider states an incidental finding on the op report, it becomes diagnostic. I have had many discussions with auditors and the providers. I come across the same issues of "Screening colonoscopy - incidental diarrhea." Sorry Doc, it is not a diagnostic study due to that symptom of diarrhea. Since I am unable to code off of anything but the report when I do a procedure, I stress to the provider that any and all info that is pertinent needs to go under the indications. Also, we stress to the providers that they do not tell the patient that it will be covered under their preventative services, because not every insurance plan has preventative services. Unfortunately nothing is perfect and some providers insist that since it is their first colonoscopy it is a screening even with symptoms.

1. It would be considered diagnostic because they have symptoms, whether this is their first colonoscopy or not.

2. Just because a symptom is stable does not mean it is not important. It is still a symptom and as such it would be a diagnostic test.

Education is the only way I could see to help rectify these issues. If you feel that your information is falling on deaf ears, it may be time to bring in an auditor or third party. Good Luck.

Christine Medvetz, CPC

 

[Tine]

We are only allowed to code off of the OP note, and if it does not state the symptoms, we cannot pull them from something else. There are times when the doctor will do an H&P right before the procedure, sort of an updated note, and they state symptoms. We ARE allowed to use that note since it was done at the same time, however, most providers only pull the previous office note into that block, and that is not allowed to be used to code.

In the case of them not documenting the symptoms, that is something that needs to be addressed as it is not the correct info for the patients procedure. Education is the only way I know to do that, and not all providers are receptive to it. Do you have an auditor that can help you with this to form a plan to approach the providers? We below to a large hospital and have a separate auditing department and they are absolutely wonderful when it comes to issues like this. I wish I had a better answer and help but unfortunately I have come across the same issue and can only code from what the OP note reports. If push comes to shove, it is the doctors documentation that is the issue. I had to use the word but I wonder if it would borderline on fraud if the doctor does not state all that is wrong with the patient under the reason/indications as to why they are doing the colonoscopy. Maybe that would be something for a separate thread with a different title.