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Need CPT and dx code

  1. #1
    Charlotte, NC
    Default Need CPT and dx code
    Medical Coding Books
    Just curious how any of you might code a screening for dysplasia.

    Here's the scenario:

    Pt has a 22 year hx of Crohn's (right off the bat screening goes out the window in my mind). Doctor wants to do a screening for dysplasia. Those are the indications.

    His findings are Crohn's (shocker) and does a biopsy.

    We code a 45380 (colon w/bx) with 555.1 (Crohn's-large intestine).

    Pt calls yelling and screaming that the doctor told her it was a screening.

    To my mind, I say no, she has a history of Crohn's, Crohn's can be a cause of dysplasia and to screen for dysplasia would be akin to a "rule it out" which you can not code.


  2. #2
    If the doc is indicating that the purpose of the procedure is for 'screening', I would go with the 'screening' dx and then the findings...

  3. #3
    Charlotte, NC
    Well first, pt does not have medicare, so "screening" dx would be second according to the commercial payer, but to my knowledge there is no screening for dysplagia. It would be an unspecified screening in both dx and CPT I guess.

    But the doctor wanted to "screen" for dysplagia, doesn't that imply "ruling out" that dx? And you can't code "rule out".

    So what CPT and ICD-9 codes would folks use for this "screening"?


  4. #4
    You are right!! there is no screening for 'dysplasia'...the other dx I can think of is V82.9 "special screening for other specified conditions" but if it for commercial, then I would go with your coding 45380/555.1

    It will be interesting to hear other feed back on this scenario!!!

  5. #5
    I would ask your doctor if he did this "screening" because of the Crohn's or was he going to do this procedure regardless. I think this would help you code it the way he intended. I do see why you coded it the way you did and I probably would have done the same thing but asking your doctor what his intentions were will help in this scenario. Hope this helps!
    Susie Corrado, CPC
    ENT Coding/Billing

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