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45380 Colonoscopy w/HX of Crohn's

  1. #1
    Default 45380 Colonoscopy w/HX of Crohn's
    Medical Coding Books
    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"?

  2. Default
    I would definitely code the Crohn's especially if they are still on treatment. The same is true for cancer. If they are still being treated or even up to a year after you code it as a current condition. It is not considered a "history of" until they have been free of disease for a year. I would think the same is true with Crohn's. My opinion, anyway.

  3. #3
    Was the patient referred to your office for a "screening"? Does your doctor say anything on the op note about doing the colonoscopy for Crohn's? I would go by what the doctor states is the reason for the colonoscopy on the op note. More than likely it will state Crohn's but you have to go by what is documented.
    Susie Corrado, CPC
    ENT Coding/Billing

  4. #4
    I would certainly check the documentation and code the Crohns if that is what is stated. Based on most clinical guideline coverages you will not find another dx for the patient, in this case, that supports the 45380. I would also code the long term med use as a secondary to further substantiate the need (for the bx) and as an explanation for the patient being asymptamatic if the insurance company asks you to provide further documentation ( this should be stated by the physician in the op note).
    Kimm Hall CPC, CMSCS, CGCS

    If you live to regret then you have not learned lifes lessons.

  5. #5
    The doctor states that the colonoscopy is being done as surveillance for a patient with a 25 year history of Crohn's who is asymptomatic and still on meds for Crohn's. He does not state how long the patient has been asymptomatic, but his final DX is "grossly normal colon".

  6. #6
    What is his reason then for doing a colon w/biopsy?
    Kimm Hall CPC, CMSCS, CGCS

    If you live to regret then you have not learned lifes lessons.

  7. Default
    From what I'm reading in your post, I would charge it as screening with the additional dx of crohn's disease. Even though the patient is asymptomatic, it's obvious the provider is still following up on the issue.


  8. #8
    I don't think it can be coded as a screening because of the patient's history. I believe he's doing the biopsy to determine if there are traces of microscopic colitis.

  9. #9
    Check your pathology report and see if there are in fact traces of colitis. I also think that you can still code the Crohns disease. While the physician states the pt has a 25 year hx and is asymptomatic, the patient is still being actively treated for the disease with medication, the procedure is being done for surveillance of the progression or recession of the disease while on the medications.

    I hope this helps.
    Kimm Hall CPC, CMSCS, CGCS

    If you live to regret then you have not learned lifes lessons.

  10. Default
    Thank you for your input.

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