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screening vs diagnostic

  1. Smile screening vs diagnostic
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    We have a 49 y/o female who came in office for itching on outside of rectum area she also has some rectal pain/bleeding due to large external hemmorrhoids. Pt given benedryl and hydrocortisone cream. pt seen back in office states itching and pain better, still having some bleeding with constipation. At that time dr recommended flex sig for further evaluation. Pt didn't have this done because she has 10,000 ded for medical. one month later she has seen family doctor back for rectal pain and itching and has been referred back to GI. Question: Since inital time pt has turned fifty and wants to have screening colonoscopy.. (She has 100% screening coverage). Could this be considered screening? ( Think I know answer, just wanted reassurance.

  2. Default
    The patient has symptoms, she cannot be a screening colonoscopy.

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    agree with Sandy5 :-)

  4. #4
    Location
    Boise, Idaho
    Posts
    424
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    I say we send all questions like this straight to ObamaCare

  5. Default
    We don't want to involve politics here but "syllingk" - you make a good point.

    Patients tell the surgeon they don't want their symptoms listed (....because their 'screenings' are covered 100%.) So if the surgeon chooses to list 'screening' as the reason for the colonoscopy on the op note, but lower GI symptoms are listed as the reason for previous visits, we should follow the op note only?

    Even if it isn't as blatant as that, savvy patients will learn (if they haven't already) what symptoms to hide/withhold from their doctors because of payment/lack thereof. Patient care will only suffer if patients can't be truthful.

    And - to make it all more confusing - policies are being changed as we speak by the commercial payers for future CRC screening benefits, adding exclusions for 'if you have a prior history of polyps' or 'if there is a family history' - so they are not going to follow the logic of a 'high risk screening' - even if there are no symptoms.

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    Just playing devil's advocate....

    JenReyn99- How would you determine whether or not the doctor is "just jotting it down" or intends for it to be a part of the procedure documentation?

    I agree that this is a very grey area of coding, and that the patient should not have to suffer. But, coding should be based on the actual documentation, regardless of our interpretation of why the provider is documenting.
    Tracey Thompson, CPC, CPPM

  7. #7
    Location
    Charlotte, NC
    Posts
    534
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    Per Medicare guidlines a pt needs to be asymptomatic for it to be a screening. If a pt comes in with a change in bowel habits unless it is already under control and being treated by another doc, it would be diagnsotic not screening. Doesn't matter what the doc says really.

    Scenario (I'm the doctor):

    My 55 y/o patient comes to see me after a trip to Mexico with diarrhea. Probably from the food or water he ate/drank on the trip. He also has a personal history of polyps and is due for a screening. Well since I think about his history and it's time for the screening I ignore the diarrhea since it's probably secondary to what he ate and schedule him for a screening. Pt comes in for the screening but has not been cleared of the diarrhea symptoms.

    Then I get audited by a RAC. They ask why I did a screening when the pt came in with symptoms of the digestive tract.

    How do you know what is causing the symptoms? Sure you can check hemmoroids and decude a rectal bleed is from them and do a screening since you cleared the pt of the rectal bleed symptoms. But you can't take for granted internal symptoms.

    What if the pt from my scenario was found to have a some internal issue like a fissure, colitis or some other issue during the screening? that would be a huge red flag that something was causing the diarrhea, and hence it should never have been a screening.

  8. #8
    Location
    Charlotte, NC
    Posts
    534
    Default
    Jen,

    Mexico was an example I created.

    But to your other points....

    It doesn't matter if the pt came in for a screening. If they tell the doctor either by the doctor asking questions or they tell them straight out..."I'm having lower abdominal pain, diarrhea, blood in the stool, constipation" or a myriad other symptoms of something else, it can no longer be considered a screening. You have to be asymptomatic for it to be a screening. And now commercial payors are going to get even more stringent for screenings.

    You're going to sit there and tell me a pt came to your doctor for a screening, during the intial visit the pt let's it slip they've had recent rectal bleeding but that's not the reason the pt came in. So you code the actual procedure for medicare G0121, V76.51, 569.3?

    Payors will pay the claim because most systems only see the first and second codes listed. But I'd be willing to bet on an audit, your money would have to be returned.

  9. #9
    Default
    So what about an asymptomatic patient with a history of polyp 7 years prior? MD states screening and polyp is once again found and removed.

  10. Default
    I work for a GI practice & personally if you have an order from the pcp for a screening colonoscopy the patient is entitled to have this due to the fact that she is 50 & has never had one. When billing the primary dx is V76.51. If she has polyps, hemorrhoids, colitis whatever that is listed as the secondary dx.

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