Wiki HELP!! Does this visit qualify for a E&M prior to screening colonoscopy.

jojo1uf

Contributor
Messages
20
Location
Nesconset, NY
Best answers
0
Hi All,

Our provider coded the below with a 99203 with dx Z86.010 (History of colon polyps). Patient has Medicare. Our compliance department performed an audit and provider failed audit due to this case. Compliance stated that an E&M prior to screening is not allowed for Medicare. (which is correct). However, the provider is stating because the patient is not "healthy"; patient has afib, cancer - that this is a risky procedure for patient and that E&M should be allowed.

Any thoughts are appreciated.....


I had the pleasure of meeting this 78 y.o.male presenting for his screening colonoscopy. He has a history of colon poylps, last colonoscopy was negative for polyps five yrs ago but he had colon polyps on the colonoscopy prior to this.

Past Medical History
Past Medical History:
Diagnosis Date
• Atrial fibrillation
• Basal cell carcinoma
• DVT (deep venous thrombosis)
• Squamous cell carcinoma


Surgical History
No past surgical history on file.

Allergies
Allergies
Allergen Reactions
• Bee Pollen Anaphylaxis
• Strawberry Extract Itching


Medications
Current Outpatient Prescriptions
Medication Sig Dispense Refill
• sod picosulf-mag ox-citric ac (PREPOPIK) 10 mg-3.5 gram-12 gram powder in packet Take 1 pack by mouth once for 1 dose. 1 packet 0
• Benzonatate 200 mg capsule Take 1 capsule by mouth 3 times daily as needed for Cough. 30 capsule 1
• NON-FORMULARY MEDICATION Take by mouth.
• benzonatate (TESSALON) 100 mg capsule Take 1 capsule by mouth 3 times daily as needed for Cough. 30 capsule 0
• cefuroxime (CEFTIN) 250 mg tablet Take 1 tablet by mouth every 12 hours. 14 tablet 0
• fluticasone (FLONASE) 50 mcg/actuation spray,suspension 1 spray in each nostril once daily. 1 g 5
• aspirin 81 mg chewable tablet Take 81 mg by mouth.
• Doxycycline Monohydrate 100 mg tablet Take 1 tablet by mouth every 12 hours. 14 tablet 0
• finasteride (PROSCAR) 5 mg tablet 0
• metoprolol succinate XL (TOPROL XL) 50 mg tablet extended release 24 hr take 1 tablet by mouth once daily
• predniSONE (DELTASONE) 20 mg tablet Take 1 tablet by mouth once daily. 5 tablet 0
• sildenafil, antihypertensive, (REVATIO) 20 mg tablet 0
• tamSULOsin (FLOMAX) 0.4 mg capsule Take 0.4 mg by mouth once daily. 0
• XARELTO 20 mg tablet 0

No current facility-administered medications for this visit.


Social History
Social History

Social History
• Marital status: Married
Spouse name: N/A
• Number of children: N/A
• Years of education: N/A

Occupational History
• Not on file.

Social History Main Topics
• Smoking status: Former Smoker
• Smokeless tobacco: Former User
• Alcohol use Not on file
• Drug use: Unknown
• Sexual activity: Not on file

Other Topics Concern
• Not on file

Social History Narrative
• No narrative on file


Family History
No family history on file.

OBJECTIVE

Vitals
Blood pressure 120/70.

Review of Systems
Review of Systems -History obtained from the patient
General ROS: negative for - chills, fever, malaise or night sweats
ENT ROS: negative for - hearing change or nasal discharge
Hematological and Lymphatic ROS: negative for - bleeding problems, jaundice, night sweats or pallor
Respiratory ROS: no cough, shortness of breath or wheezing
Cardiovascular ROS: no chest pain or dyspnea on exertion
Gastrointestinal ROS: see HPI
Genito-Urinary ROS: no dysuria, trouble voiding or hematuria
Musculoskelatal ROS: negative for - joint pain, joint stiffness or joint swelling
Neurological ROS: negative for - confusion, gait disturbance or headaches
Physical Exam
General appearance:
Head: Atraumatic
Eye: EOM intact; no icterus
Nose: no discharge
Oral mucosa: moist
Neck: no JVD, neck supple, no lymphadenopathy
Lungs: b/l a/e present. No wheezing. No crepitus
Heart: S1S2 present, no murmur
Abdomen: soft, non tender, BS+, no organomegaly, no CVA tenderness
Extremities: Atraumatic, trace pedal edema. No cyanosis or clubbing.
Skin: no rash
Neurologic: AOx3, cranial nerves II-XII intact, power b/l normal

ASSESSMENT
This is a 78 y.o.male presenting for his screening colonoscopy, history of colon polyps in the past.


PLAN
30 minutes face to face was spent with the patient 50% devoted to counseling.

The risks and benefits of any endoscopic procedures including colonoscopy have been discussed with the patient including bleeding, infection, missed lesions or perforation and alternatives to the procedure have been discussed. The patient consents to proceed.

The patient will hold his xarelto 5 days prior to the colonoscopy and check with his cardiologist about this.
 
This should be ok. You always code first for what the patient came in for. If this was not the primary reason for the visit than you would want to code this second. Otherwise I used a program called Find-A-Code to scrub the claim and it did not come back with any errors.
 
Top