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45380 Colonoscopy w/HX of Crohn's

  1. #11
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    Quote Originally Posted by coderguy1939 View Post
    Patient has a 25 year history of Crohn's disease, is clinically asymptomatic maintained by use of long-term medications. The patient came in for a surveillance colonscopy and there was no evidence of Crohn's. Since the patient is still on treatment can this be coded as Crohn's disease even though the entire colon is "grossly normal"?
    If the intention of the scope was to screen, then V76.51 is dx #1, 555.9 #2. Code 45380 dx2, dx1. You want to list screening as the original intent of the procedure, but bxs were done for crohn's, so you have to link that as the first code on the line item.

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    The doctor is doing surveillance to determine the status of patient's Crohn's disease, not screening for neoplasms. So, what I'm getting is that the Crohn's can be coded even if he state preoperatively that the patient is asymptomatic and the final DX is "grossly normal colon".

  3. #13
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    Quote Originally Posted by coderguy1939 View Post
    The doctor is doing surveillance to determine the status of patient's Crohn's disease, not screening for neoplasms. So, what I'm getting is that the Crohn's can be coded even if he state preoperatively that the patient is asymptomatic and the final DX is "grossly normal colon".
    I say absolutely. The patient is obviously asymptomatic because of medical intervention.

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    Thank you for your help. I appreciate it.

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