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Selection of screening diagnosis or medical diagnois

  1. Default Selection of screening diagnosis or medical diagnois
    Medical Coding Books
    When coding for colonoscopies, if a patient's H & P states diagnosis is for screening, but the review of symptoms it states constipation, how would the first diagnosis be coded? This particular patient has Humana.

    I have been going by symptoms if any are listed. Patients tend to get upset if they have to pay more. And say this was for screening. The doctor does snare, hot biopsy or cold biopsy.

    What do I do in a situation like this? The doctor's office uses the screening as first listed diagnosis and does this for Humana patients only.


  2. #2
    Columbia, MO
    It does not matter the insurance company it comes down to correct coding. If the patient presents for screening then they are asymptomatic so if there are symptoms listed then are these things the patient has experienced in their past, if so then it is screening. The guidelines state screening is the first listed dx regardless of findings. If the patient is symptomatic then it is contraindicated to perform screening. So you must first ascertain the reason for the exam. If it is screening then that is the first listed and the findings are secondary regardless of the procedure performed.

    Debra A. Mitchell, MSPH, CPC-H

  3. Default
    Okay. The patient sees doctor for screening. But, in the review of systems, findings are constipation. Then this is considered medical not screening. Do I understand this right? This is how I have been coding it. But, other Doctors office said they are using screening diagnosis for Humana patients because of so many complaints.

    I want to be sure I understand correctly. I appreciate the info.


  4. #4
    Columbia, MO
    No the patient comes in for screen then that says that patient had no symptoms upon presentation. If they did then the physician would have to document a cheif complaint of constipation. In review of systems a lot of times the physician asks the patient if they have experienced any recent constipation and the patient sys yes. this is not the same thing as the patient presenting for a problem of constipation. You may want to clarify with the physician. But to be diagnostic the physician would need to state that the colonscopy is to further examine the patient for causation of the constipation.

    Debra A. Mitchell, MSPH, CPC-H

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