Wiki Screening Colonoscopy, Biopsies for 787.91


Local Chapter Officer
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A 51 year old patient came in for a screening colonoscopy. The indication on the op note is Screening. In the body of the note however, the provider states "Biopsies were obtained to look for microscopic colitis, because of infrequent diarrhea". The provider is telling me that the biopsy is incidental to the screening colonoscopy since he wouldn't have done a scope for the diarrhea but since he was already there, biopsies were taken. Is there any way that this can still be coded as screening and not be considered diagnostic?

To me, no. Others will say you need to code the screening because that's what the pt came in for but once the doctor put in "for diarrhea" the screening went out the window.
I hesitated before responding to this, because this topic can turn into a very heated discussion for some. This scenario is my personal coding nightmare, and a frequent one. We have researched and debated this issue in our practice for years. I really do see more than one side to this, and I don't think either side is totally right or wrong. As coachlang said, many others will tell you it's a screening. Many others will tell you it's not. I think in some cases, it is still a screening service. However, like it or not, there are many factors that will come in to play, and it's hard to give a final answer that's used across the board. In this particular case, with my physician's input, I would most likely code it a screening service, and add the diarrhea as a secondary dx. It's up to the insurance company if they will still allow the patient to access their screening benefit.
Thank you both for your insights on this! It's been very helpful.
I agree with Bridgette.

Try the diarrhea as a secondary. Medicare lists it on the NCD as a covered dx for screening, though I don't know why since they also describe a screening as asymptomatic.
What supports the screening not having changed with the addition of the diarrhea is the term infrequent which it sounds was discovered during intake at the time of service. But, before coding and submitting I'd wait for your histology to diagnosis accurate findings (microscopic colitis, ect...) in addition to screening and diarrhea. Again, just another opinion on the subject. :)