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Patient complaint DX versus Screening Colonoscopy

  1. Default Patient complaint DX versus Screening Colonoscopy
    Medical Coding Books
    Patient calling in states their colonoscopy should have been coded as a Screening. We coded 45378/564.00,562.10. I sent the consult and Op note to another coder in our facility and she also agrees that this was not a screening colonoscopy. Do you agree with us?

    CC: colonoscopy consult.

    History of Present Illness:
    Patient received our recall letter and presents for consideration of repeat colonoscpy. last scope was in 2005 and showed only extensive diverticulosis. denies any change in bowel habits or blood in stool -- but has fairly chronic severe constipation

    Past Medical History:
    Reviewed history from 11/18/2009 and no changes required:

    Multi-system atrophy
    -- primary sx is ataxia
    -- followed by Neurology
    Urge Incontinence
    migraines with hemiplegia

    Past Surgical History:
    Reviewed history from 11/18/2009 and no changes required:

    C - section
    Bunion Repair- 3 surgeries
    Colonoscopy 2005 (diverticulosis)

    Family History:
    Reviewed history from 11/18/2009 and no changes required:

    sister- Chrohn's disease, high cholesterol
    father- lung cancer
    sister- ETOH, drug abuse
    brother- hypertension, rheumatoid arthritis

    Social History:
    Reviewed history from 01/15/2008 and no changes required:

    Married; no tobacco or ETOH

    Risk Factors:

    Tobacco use: current
    Year started: 2002
    Passive smoke exposure: yes
    Drug use: none
    HIV high-risk behavior: no
    Caffeine use: Drinks coffee, tea 3-5 times per day.
    Alcohol use: no
    Type: No alcohol use.
    Exercise: yes
    Times per week: 3-4 /wk
    Type: walking, other
    Seatbelt use: 100 %

    Family History Risk Factors:
    Family History of MI in females < 65 years old: no
    Family History of MI in males < 55 years old: no

    Colonoscopy History:
    Date of Last Colonoscopy: 06/10/2005
    Results: Diverticulosis

    Review of Systems

    The patient denies fever, weight loss, dysphagia, chest pain, palpitations, dyspnea on exertion, changing cough, abdominal pain, bloody stools, change in bowel habits, dyspepsia, reflux, easy bleeding or bruising, and anesthesia reactions (allergy).

    Complains of constipation.

    Vital Signs:

    Patient Profile: Years Old
    Weight: pounds
    Temp: 96.9 degrees F tympanic
    Pulse rate: 68 / minute
    Pulse rhythm: regular
    BP sitting: 124 / 78 (left arm)
    Cuff size: regular

    Vitals Entered By:

    Physical Exam

    well developed, well nourished, in no acute distress.
    no deformity or lesions with good dentition.
    no masses, thyromegaly, or abnormal cervical nodes.
    clear bilaterally to auscultation.
    non-displaced PMI, chest non-tender; regular rate and rhythm, S1, S2 without murmurs, rubs, or gallops

    Test Management:

    Tests Reviewed:

    Impression & Recommendations:

    Problem # 1: Preventive Health Care (ICD-V70.0)
    With family hx of polyps and with constipation will proceed with colonoscopy.

    Proceed with colonoscopy. The risks, benefits, and possible complications including the possibility of perforation, bleeding, missed lesion & anesthesia reactions were explained. Pt understood and agreed to proceed, signing the consent form. We will schedule this shortly.

    Patient is ASA class II, MAC not indicated

    Medications Added to Medication List This Visit:

    Note able to paste this note so I will type a brief description

    Indication: constipation
    Anal Canal: Normal
    Rectum: Normal
    Sig colon: Diverticulosis, Moderate
    Descend Colon: Diverticulosis, Moderate
    Splenic Colon: Normal
    Trans colon: Normal
    Ascending colon: Diverticulosis, Mild
    Cecum: Normal
    Ileum: Normal
    Impression- Mild Diverticulosis-562.10
    Divertiuclosis of colon- 562.10

    CPT code: 45378.

  2. #2
    Greater Orlando
    Why does patient think this should have been classified as a screening colonoscopy?
    Ron McKenzie, CPC-A
    Greater Orlando FL Chapter

  3. #3
    We run in to this problems a lot. Was the constipation the reason the appt was scheduled or was it just something that came up during the visit? If it was just something that came up during the visit I don't know that I would consider it diagnostic. I think if we were all asked during a GI appt we could definitely say that at times we have GI issues but I dont think that should change it from screening to diagnostic if they came in for screening. It is really up to the physician- you can see a patient for screening colo and they state they have constipation. Dr. decides to do the colo for screening but treat the constipation medically (meds, high fiber, increase water intake, etc.). It really is a grey area that makes this specialty so much fun - ha ha!
    Susie Corrado, CPC
    ENT Coding/Billing

  4. Default
    It states in your report as Problem #1 that it is Preventative using the v70.0 would that not be screening??? It sounds to be like constipation is incidental.

  5. #5
    Charlotte, NC
    It states near the bottom:


    this right here takes away the screening option.

    So while the patient came in for a consult based on a recall, during the consult the pt complained of "severe constipation". The doctor then said "yes, we'll still do a colonoscopy but now it's becaue you have a problem and I need to see why you have this problem."

    Not sure but it reads like the pt came in for an OV first and then the procedure. So during the OV the pt said something that changed the basis of the doctors thoughts for the procedure.

  6. Default Colonoscopy dx vs sx
    The patient came in to be seen due to the Dr sending the patient a reminder card stating she needed to be seen for a f/u colonoscopy due to her colonscopy in 2005 findings of diverticulosis.
    If patient had never had a colonoscopy and came in for a consult to disucuss having this procedure and the patient mentioned she's having constipation I would have coded it as a Screening. But the provider had this patient come in to the office to schedule another colonoscopy due to her 2005 findings.
    Patiet thinks this should be screening due to it being 5 years plus since her last colonoscopy. Patient was told by our referral department that if the procedure ended up being a screening colonoscopy insurance would cover in full. If this procedure was considered Diagnosis colonoscopy they patient would be responsible for 70% since there ded was met for the year. What a headache!!!

  7. #7
    Charlotte, NC
    I believe Medicare guidelines state diverticulosis makes the pt high risk and thus a screening within the 5 yrs is warranted.

    So the recall is based on screening guidelines.

    So the pt came in for a screening. I have no problem with that line of thought. But what happened during the OV changed the procedure to diagnsotic instead of screening.

    From reading these forum boards many think because you have a history it is no longer a screening. It still is as long as the pt is not having complaints of symptoms. Hence we use the G code G0105-screening colonoscopy-high risk. It's still a screening but it is now considered high risk and it needs to be done more often due to the extenuating cirumstances (in this case diverticulosis).

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