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screening colonoscopy

  1. #1
    Default screening colonoscopy
    Medical Coding Books
    When a patient is having a colonoscopy and they are coming in for a screening with a family history of colon cancer, which is the principal DX; V16.0 or V76.51??

  2. Default
    V76.51 is the principal followed by History code. If any abnormality is discovered during the screening code the screening, abnormality and History code.

  3. Default
    Hi,
    You need to code screening code - V76.51 as a primary followed by history code-V16.0 .

    Regards,
    Nalini CPC

  4. Default
    First of all, the H&P must state which family member had colon cancer because it only counts as family history if it is a parent, sibling or child of the patient. If that is the case ONLY V16.0 is coded. V76.51 is age appropriate screening (low risk). Even though V16.0 is history of, it is still a screening code and you don't use two. Remember, ANYsymptoms relevant to a colonscopy takes precedence over a screening, so if there is constipation, diarrhea, abdominal pain, BRBPR, etc. the Diagnosis code comes first even if the patient was intiallly coming in for a due screening.

  5. #5
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    Default
    Quote Originally Posted by Candice Peckham View Post
    First of all, the H&P must state which family member had colon cancer because it only counts as family history if it is a parent, sibling or child of the patient. If that is the case ONLY V16.0 is coded. V76.51 is age appropriate screening (low risk). Even though V16.0 is history of, it is still a screening code and you don't use two. Remember, ANYsymptoms relevant to a colonscopy takes precedence over a screening, so if there is constipation, diarrhea, abdominal pain, BRBPR, etc. the Diagnosis code comes first even if the patient was intially coming in for a due screening.
    You can use symptoms ONLY if the patient complains of a symptom and that is the reason for the exam, it does not get scheduled as a screening and then suddenly switch once the patient gets there, because they list or answer a question which shows they have had symptoms in the past. This was scheduled as a screening so it still is.

    Debra A. Mitchell, MSPH, CPC-H

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