Wiki E/M Coding dx screening colonoscopy

[daisygirl]

I am auditing a note for E/M service where the provider (an internist) is using a dx of
V76.51, screening malignant neoplasm colon

CC: GIA for screening colonoscopy
HPI: Abdominal pain, has burning after food, not on daily treatment. Heartburn frequently aggravated with food for the past 6 months
ROS: Denies Constipation, diarrhea, nausea, rectal pain, rectal bleeding and vomiting

EXAM:
GENERAL APPEARANCE: pleasant, NAD
HEART: regular, normal S1, S2, no murmurs
LUNGS: clear, no crackles or wheezes
ABDOMEN: soft, BS present, no guarding or ridigity, no masses felt

ASSESSMENT: V76.51

TX PLAN: Start Golytely Solution Reconstititued, 236 GM, 1ml now orally once a day

Question:
This is an internist, is it appropriate for him to use this dx for this visit, since he is not doing the actual screening?
Even though this is an established patient, he coded this visit 99202.

 

[dsantos1]

V76.51

Daisygirl,

If the patient is an established patient that has been seen within the last 3 years then 99202 is inappropriate. An established code must be utilized: 99211-99215. The DX code V76.51 should be used for a colonoscopy only. You should code out the abdominal pain and the heartburn (789.00, 787.1)

Hope this helps.

Deb

 

[mitchellde]

if the patient is symptomatic then it cannot be a screening, if the patient is presenting for screening then the question is are these symptoms current, and the reason the patient is seeking treatment. Or is this past history and the patient is seeking their screening benefit. If the screening has been prior scheduled and the patient is currently asymptomatic then you cannot charge for a pre op visit.

 

[daisygirl]

It seems the patient is symptomatic, however, the physician's CC reads "screening colonoscopy". I'm thinking the screening should be done by a GI specialist using the CPT codes 45378 - 45385 with the dx V76.51. As an internist, isn't it inappropriate for him to use this dx since he is not doing the screening?

 

[daisygirl]

Deb,

With reference to the latter part of your response "is this past history and the patient is seeking their screening benefit. If the screening has been prior scheduled and the patient is currently asymptomatic then you cannot charge for a pre op visit. "

The last part of note states the procedure was scheduled for a later date, however, there's no past history of a screening, it seems the patient has symptoms and is seeking for his screening benefit, can the internist charge for a pre-op visit?