Wiki Colonoscopy Question

[amowens854]

The following is typical operative note documentation by our physicians for patients returning for surveillance colonoscopy (24 months or greater) when no pathology found on current colonoscopy:
Preoperative Dx: personal history of colon polyp,
Postoperative Dx: personal history of colon polyp
Procedure: COLONOSCOPY.
The diagnosis and timeline fit Medicare and other insurance requirements for high risk screening colonoscopy (G0105).
My question is: MUST the physician document the procedure as SCREENING colonoscopy in order to meet coding guidelines and assign G0105 to this procedure?
If you could point me to specific guidance I would appreciate it, as this is needed as evidence to establish workflow protocol.

 

[thomas7331]

In my opinion, the information above does not support assignment of either the G0105 or of the ICD-10 code Z12.11 and I would not be comfortable assigning either. The fact that a patient has a history of colon polyps is insufficient, in and of itself, to know whether or not the procedure is being performed for diagnostic, therapeutic, or screening purposes. The record needs to reflect the reason that the test is being done. With just this much documentation, we do not know if it is being done to follow up or monitor a recently removed polyp, or if it was due to a symptom which the patient reported, or if it is simply a scheduled screening/surveillance at the recommended interval. If this was all I had in the record, I would query the provider for additional information as to why the procedure was scheduled.

 

[Cruzc0710]

I have a different situation. I work at a hospital and code endocopies from the surgery center facility. my question is from the H&P stand point from the gastro office visit. when the H&P suggests a diagnostic colonoscopy dues to obvious reason of pain , rectal bleed on a MCR patient who hasn't had a colonoscopy in ten years, but the Op report clearly states screening and the hospital billing charge is diagnostic 45378. Do I code it as a screening and request they change charge to G0105 or code it as diagnostic. Our doctors obviously use a template which I believe is causing the problem , but what are my options ?