colonoscopy screening vs colonoscopy diagnostic

Lisa Griffin

St Louis West Missouri
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Question, we seem to be having some confusion when it comes to ordering colonoscopies. For simple, asymptomatic patients who just need a screening we are using Z12.11 plus 45378. It seems that this confuses some of our patients when they see that 45378 is colonoscopy, diagnostic. If we are doing an actual diagnostic colonoscopy we still code with 45378 but use an appropriate ICD-10 like K59.00 constipation, R19.4 change in bowel habits, etc. I try to explain to them that 45378 is very broad and that it is a screening unless the physician finds something (except in the case of using a code other than Z12.11). Is this correct? Thanks!


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To my knowledge that is correct. One way to explain it is that only Medicare are a few other specific insurances take the G0121 or G0105 code that are for low risk and hi risk screenings. Those that don't take those codes use the accompanying diagnoses, and occasionally modifiers, to determine that the 45378 was a screening. However, we also explain that some insurances have been ruling that once anything like a polyp has been found, it is no longer a screening as you mention. This is contradictory in that coding guidelines a screening can be done with far more Z codes, even Z86.010. It seems insurance companies and even separate policies, pick and choose what is considered screening outside of Z12.11. I'm fairly certain this has even happened on a patient's first colonoscopy. We have also had difficulty even with length of time between high risk colonoscopies even though the rules state the shorter time period between screenings It would be much more convenient if all just followed the same rules regarding screening vs. diagnostic.
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