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different dx for office visit and colonoscopy

  1. #1
    Lauderdale Lakes
    Default different dx for office visit and colonoscopy
    Medical Coding Books
    My doctor and billing office manager are disagreeing what diagnosis to use. Patient made an office visit appointment for a colorectal screening. When the patient came in for the visit he stated he has consitpation. The doctor wants to use constipation for the office visit but use the screening code for the colonoscopy. My billing office manager said that he needs to use the constipation code. Who is right?

  2. #2
    Kansas City, MO
    What was the primary reason for the OV and the scope? THAT will be your primary dx.
    The OV for a screening colonoscopy is inclusive of the procedure. Sounds to me like the OV was just a work up before the scope, and the scope was a screening...he just happened to also have constipation....which is not alone necessarily enough to make it a diagnostic scope.

    My two cents

  3. Default
    I would have to agree with Linda. If the initial reason for the visit was a screening and constipation is the only issue before the procedure then the OV should be a work up before the procedure.

  4. #4
    Columbia, MO
    I agree also. This looks like a scheduled screening. Many times when asked the patient's will admit that they have had some constipation previous. This is very different from the patient making an appointment to have the cause for constipation investigated. Also it does not make sense on the day of the colonoscopy to proceed with a colonoscopy if in fact the patient is constipated at that time.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Lauderdale Lakes
    Thank you for your help. The patient did make an office visit appointment to have a screening colonoscopy. When he was in the room with the doctor is when he mentioned that he had constipation. I was unsure of how to bill this since my doctor and office manager could not agree on the diagnosis.

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