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Followup or screening challenge.

  1. #1
    Question Followup or screening challenge.
    Medical Coding Books
    Patient had colonoscopy 6 years ago for rectal bleeding and secondary dx of family hx of CC. Nothing found at that time other than hemorrhoids. He is now here for "follow up" colonoscopy. My question is, is it a followup when nothing was found on the first one? Is the definition of a followup v67.09 only for following up to a finding of a polyp or can it be a followup to a previous colonoscopy? And if nothing was found, would it be a screening for colon cancer v76.51 due to family hx of colon cancer? Is okay to call it a follow up to a colonoscopy, when nothing was found? Clear as mud? Oh, this one is all normal also, no findings.
    Last edited by Alta; 06-30-2009 at 06:40 AM.

  2. #2
    Is it a medicare patient?

  3. #3
    I know there is much confusion coding colonoscopies these days.
    It sounds to me like it is a "follow-up" (poor choice of words..for them to use) to rule out CC since they have a family history. I would use the V76.51 code for that, because it sounds more like a screening to me. Did the dr state "screening" anywhere in his op note or H&P? There are time limits for such follow-ups (i.e. 5 years, 10 years). If the pt is Medicare, I would use the V76.51 if nothing was found and then also use the fam hx cc code. There is a lot of information about "screening colonoscopies" and whether it counts as a follow up or just a screening; depending on the age of the patient, the risk, the history, last exam date, etc. You can find info on the CMS website (for medicare rules) and usually each different isurance company will define their rules on their own websites as well. Hope some of this helps a little?!

  4. #4
    Default No, not Medicare
    The doc states followup all the way through, 5/6 year followup in history and in op heading. I just was not sure if it could be a followup if nothing was found on the last one. The rules are pretty clear about it being a followup when a previous one found a polyp, but to a clean colonoscopy, not really much to be found. I tend to get these little fall through the crack scenerios! Thanks for your help.

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