Wiki Op-report for screening colonoscopy. SOAP indicates symptoms

[bench]

Hello. I hope to get an advise from this inquiry. We have this doctor who dictates his op-report for screening colonoscopy with no other indication, but the SOAP assessment indicated symptoms like chronic idiopathic constipation and also noted, "the sole indication for colonoscopy is for colon cancer screening". If this claim is billed for screening with the symptom, that will contradict the screening procedure policy, but because of the note, should this procedure be considered as a screening colonoscopy and bypass the symptom? Should the diagnosis code/s only be based with the op-report? Thank you and I appreciate your response.

 

[nickelclaw]

this is a screening with a chronic condition so Z12.11 and the K59.04 and if G code or 45378 turns to diagnostic then PT for MCR or mod 33 will need added to procedure.
Since the assessment states symptoms "Like" don't code the K59.04 that would be what he is looking for. Just Z12.11

 

[bench]

Hi N. Thank you so much for your response. I really appreciate you. In case the assessment is symptom "of chronic idiopathic constipation" will this change anything from "like"? Everything I can find from reputable sources only says one thing, patient needs to be asymptomatic. I am confuse what will be the exception if the patient was assessed with symptom/s but despite doctors wants to bill with a screening. The SOAP did not mention that the symptom was resolved or at least rule out the chronic condition by indicating the source whether it maybe dietary or cause by meds etc...Any advise when to exclude symptoms to be able to bill for screening colonoscopy? Thank you so much.