Wiki History of Colonic polyps

[Ksumansky]

Patient coming in for colonoscopy with a history of colonic polyps. Not sure when the last colonoscopy was performed. polyps found in the ascending and sigmoid colon and both was biopsied. how would you code this.

45380 v76.51, 211.3, v12.72
or
45380 211.3, v12.72
or
45380 211.3

???????

Thank you for your time!

 

[mbort]

45380 211.3, v12.72 is my answer (you made no mention in your entry that this was a screening)

 

[dmaec]

I agree with mbort - I'd would also code it; 45380 211.3, v12.72
{that's my opinion on the posted matter}

 

[Ksumansky]

oh sorry, the doctor's H&P stated screening/hx of polyps.
OR Report stated screening, but no mention of hx of polyps

 

[Lisa Bledsoe]

Question: Is this a Medicare patient? It would require a different way of listing/linking the dx codes if it is...and if it was indeed screening...

 

[Ksumansky]

Not Medicare, Preferred blue Highmark

 

[mkj2486]

I was taught that if a patient has a history of polyps any future colonoscopy it is not considered a screening any more. The patient has a problem that needs surveillance. The screening is the initial procedure checking for any problems that may result in cancer. Unchecked polyps may result in cancer, therefore the patient is not having a screening any more, they are being checked for additional problems due to the history of polyps.