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Screening Colonoscopy versus Surveillance Colonoscopy

  1. #1
    Default Screening Colonoscopy versus Surveillance Colonoscopy
    Medical Coding Books
    I have a few questions regarding this issue. If anyone can offer any assistance in this matter it would be greatly appreciated:

    1. What is the difference between screening and surveillance colonoscopy?

    2. A pt. comes in for colonoscopy who has a history of colon polyps, during the exam a polyp is found and removed. What is the principle diagnosis?

    3. A pt. comes in for a colonoscopy who has a history of colon polyps, the pt. has a normal exam with no findings. What is the principle diagnosis?

  2. #2
    The principal dx for 2 and 3 would be v1272 - personal hx of colon polyps. Screening is someone who has no symptoms, personal history, or family hx. Surveillance would be for someone who has a hx (polyps, cancer) or family hx. Hope this helps!
    Susie Corrado, CPC
    ENT Coding/Billing

  3. #3
    It is my understanding that V12.72 is an unacceptable principle dx and can only be used as a secondary dx. The ongoing discussion between coders at our facility is that the principle dx should be 211.3, while others say it should be V76.51.

  4. #4
    North Carolina
    Indicate the Primary Diagnosis using the International Classification of Diseases, Ninth Revision, Clinical Modification, (ICD-9-CM) code for the screening examination (colonoscopy or sigmoidoscopy), and
    Indicate the Secondary Diagnosis using the ICD-9-CM code for the abnormal finding (polyp, etc.).
    For example, V76.51 (Special screening for malignant neoplasms, Colon) would be used as the first listed code, while the secondary code might be 211.3 (Benign neoplasm of other parts of digestive system, Colon).

    Does this help?
    Rebecca CPC, CPMA, CEMC

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  5. #5
    It does, however, it is my understanding if they have a history of polyp, then it is no longer a screening, but now a surveillance and therefore you cannot use the V76.51... Please excuse my confusion, it's just that we've got some very skilled coders that have been coding these scenarios very differently and have gone through numerous audits and none have been flagged, is it possible that either way is ok?

  6. #6
    I agree with Rebecca, the guidelines indicates that the screeening dx should be coded first, also if the doctor documents that is a screening colonoscopy even though the patient has a hx of colon polyps, I document both the screening and the history dx.

  7. #7
    Greeley, Colorado
    I agree with NELENAZ. I use both V76.51 and V12.72. If a polyp is found and poylpectomy performed, use 211.3 as the third code on the claim, but as the first code on the line item. Your claim would look something like this:
    dx 1=V76.51 dx 2=V12.72 dx 3=211.3
    line item: 45385 dx 3,1,2
    Lisa Bledsoe, CPC, CPMA

  8. #8
    This goes back to a point that I have brought up several times - as a coder we are to code to the highest specificity. So, a patient with a history of colon polyps would not be coded as V7651 - they would be V1272. Screening is not specific enough.
    Susie Corrado, CPC
    ENT Coding/Billing

  9. #9
    Thank you ALL soooo much for all of your feedback!!!! You've been very helpful!! Have a great day

  10. Default Survelliance EGD/ Colonoscopy
    Pre-op dx is "Family hx of stomach and colon cancer, for surveilliance of colonoscopy and upper endoscopy."

    Post-Op dx: is "Gastritis, small hiatal hernia,internal hemorrhoids, polyp in the proximal ascending colon.

    What are the diagnosis I would use?
    I used 211.3 for the colonoscopy and 535.40 for the EGD but what about
    V16.0, would I use it and would it be primary or secondary?
    adrianne, cpc

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