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Primary Diagnosis

  1. #1
    Default Primary Diagnosis
    Medical Coding Books
    I have a chart, and on the facesheet, nurse's notes and OP Report, the diagnosis is rectal bleeding and screening. Because this bleeding is symptomatic, would I code the rectal bleed as primary, and 45378 for a colonoscopy; or V76.51 as primary, and 569.3 secondary and G0121? This IS a Medicare patient. Thanks!


  2. Default 45378 issue
    I would code the 45378 with 569.3 as primary, since that is the main reason for the exam, find out the issues with bleeding. However, I did have 1 insurance carrier want the 45378 with 569.3 first and the V76.51 second showing that if there wasn't bleeding it would have been screening. Go figure!!!!!!

  3. Default
    Ultimately every colonoscopy is done to look for cancer.

    I would not code the V76.51 primary because the reason for the scope is the bleeding and that is what is being evaluated first and foremost.

    I have had providers state that they patient is coming in for a screening and also complains of occasional rectal bleeding. These I code as a screening. It depends on what is documented.

  4. #4
    Columbia, MO
    A diagnostic test cannot be both screening and diagnostic. If the patient is asymptomatic and screening is suggested by the physician and agreed to by the patient then any findings are incidental and it is not diagnostic so the screeningis listed first and the finding secondary. If the patient s presents with sympmtoms that need investigation and the physician orders a diagnostic study then it is to look for the causation of the symtoms and there is no screening at all, so you code the symptom OR the finding if the finding is determined to be the causation for the symptom. Sometimes a physician uses incorrect verbage and states they need to get a screening to determine the definitive reason for the symptoms. They have just ordered a diagnostic study NOT a screening.

    Debra A. Mitchell, MSPH, CPC-H

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