Wiki Colonoscopy done for rectal bleeding but none found. Normal Colon/Internal Hemorrhoids. ICD-10 Code pls?

[Rybicki1]

PREOPERATIVE DIAGNOSIS: Rectal bleeding.
POSTOPERATIVE DIAGNOSIS: 1.Normal colon to cecum.
2.Enlarged grade 2-3 internal hemorrhoids.

PROCEDURE PERFORMED: Colonoscopy to cecum.
QUALITY OF COLON PREP: Excellent.
SPECIMEN: None.
COMPLICATIONS: None evident.

Insurance is Medicare - How would you code this? Would you just code 45378 with Internal hemorrhoids?

 

[pchamp25]

I would code w/45378 as this procedure as it wasn't a screening so 45378 would be the appropriate CPT code to bill to Medicare

 

[xXxPARAGONxXx]

Insurance is Medicare - How would you code this? Would you just code 45378 with Internal hemorrhoids?

Yes. With diagnoses K64.1 and K64.2 (assuming two different hemorrhoids are referred to). Any one of them can be the primary diagnosis.