Screening Colonoscopy versus Diagnostic Colonscopy

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Clemmons, NC
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Patient is having their first Colonoscopy (age 50)-Due for 1st screening, but patient reported a small amount of (K62.5 Rectal bleeding). Is this a diagnostic (K62.5 Rectal bleeding diagnosis) or 1st time Screening colonoscopy with diagnosis Z12.11 Screening for colon malignancy and add rectal bleeding as a 2nd diagnosis? We encounter this frequently. In this particular case, the patient presented for their screening, but did mention rectal bleeding. Would the outcome be different if the patient presented to our office c/o rectal bleeding and the physician determined that they were also eligible for a screening colonoscopy? Seems like semantics, but we are seeing people postponing screening because of the additional out of pocket expense. They want that 100% screening benefit coverage and will only have the procedure if it is covered at 100%. To make matters worse, the insurance tells the patient that if your doctor "will code it as screening, we will pay 100%." We can't find any black and white information on how to properly code these procedures. There seems to be a lot of confusion with the insurance carriers regarding the difference between screening, surveillance and diagnostic colonoscopies. Any feedback would be greatly appreciated.
 

dbrowne1129

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If the patient is report any symptoms at all, it is no longer a screening. This happens all the time, the patient is boarded for a screening but when the physician talks to them before the procedure, they report abdominal pain, rectal bleeding or something that is really incidental and then that's what they dictate and it is no longer a screening. It is then coded as diagnostic and then the patient gets mad because they have a copay. If the patient comes in with a symptom it is always a diagnostic colonoscopy. I have always tried to question the physician when I see that this has happened. I think what it really boils down to is education for the doctor so he understands how this can change the benefits for the patient. Hope this helps.
 
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