Wiki Screening vs. Diagnostic Colonoscopy

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pookergirl

pookergirl

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Really hoping for some solid input here. I code for the hospital facility side of a GI office and with every EGD or colonoscopy performed I have an H&P and an Op/Procedure Note to go through. There's no office visit charge on my accounts, just the procedure and everything related to that. Frequently, the Impression on the accompanying H&P will differ from the Preop Diagnosis on the Op Note. Here's an example of one from today - the H&P Impression is BRBPR, no mention of screening, but the Op Note Preop Diagnosis is screening colonoscopy with no mention of rectal bleeding. I did peek at the referral in Chart Review and patient was referred a few months back for BRBPR for a diagnostic colonoscopy. Should I code this as a diagnostic or a screening? I can't tell you how frequently this occurs and it's very frustrating. From prior queries I do know that the diagnoses on the H&P come over from the referring office, but our endo docs are signing the H&P so shouldn't they be matching for the most part? Argh. Any input is very much appreciated.
 
This happens to me all of the time. From the direction of past audits, I can only code what's on the op note.
If it comes back from billing saying "no, this was for BRBPR", then I ask the Gastro doctor to please add that dx to the op note (and it's no longer a screening.)
I'm thinking that the op notes are either partially 'canned' notes. and screening Z12.11 is the default. OR, the doctor is maybe burned out from getting yelled at for "you can't list a diagnosis for a screening colonoscopy" from all those other accounts that WANT the dx to be a screening, that they just say "it's a screeening" on every one.
No help, I know.
 
Pooker girl
BRBR is for Hematochezia see dx K92.1. Melena dx K92.2 differ red blood in stool. But really the provider should give you the dx of K92.2 or K92.1.If patient has a problem or reason for the colonoscopy(person above from note does) that is diagnostic reason. At times if over 55 yrs old doc or patient want to do check colon see if have gastro polyps then do the check as screening. I d use dx Z12.11 for screening .Some payers like modifier 32 on it as mandated. Keep following documentation from provider; many reason patient can get this colon procedure.
Blood in Stool, also known as Hematochezia, refers to the passage of bright red blood in the stool. Accurate ICD-10-CM codes are crucial for medical billing and documentation. Below are the commonly used codes for Blood In Stool: K92 dx block.
I hope helped you
Lady T
 
Hello,

I believe it would be easier to have these colonoscopy categories available to the providers so they are aware of the meanings so proper coding can be applied. Coding should not be mind reading. This would cut down on provider inquiries. This is from slide 19 from an AAPC presentation.

I don't know how you receive your charts but regardless if paper or electronically some EMRs allow for a check the box scenario before allowing you to move on. A few simple questions could lead the provider to the correct category. Coding the same specialty over and over should actually be easy, boring and monotonous not a constant mind reading 🧩.

The link below addresses various coding scenarios for screening, surveillance and diagnostic colonoscopy coding for Medicare and non-Medicare patients with ICD-10-CM, CPT and HCPCS coding. It also has presentation slides. My best wishes to you.

COLONOSCOPY CATEGORIES
 Diagnostic/Therapeutic Colonoscopy: Patient has past and/or presents with gastrointestinal symptoms, polyps, GI disease, iron deficient anemias and/or any other abnormal tests.

 Surveillance/High Risk Screening Colonoscopy: Patient is asymptomatic (no
gastrointestinal symptoms either past or present), has a personal and/or family
history of colon polyps and/or cancer. Patients in this category are required to
undergo colonoscopy surveillance at intervals of every 2-3 years.

 Preventative or Screening Colonoscopy Diagnosis: Patient is asymptomatic (no GI
symptoms past or present), is over the age 50, has no personal or family history of
gastrointestinal disease, colon polyps, and/or cancer. The patient has not had a
colonoscopy in the past 10 years.

** Diagnosis for screening colonoscopy is tied to correct diagnoses when it comes to patient share of cost.


 
mikhaila said:
Hello,

I believe it would be easier to have these colonoscopy categories available to the providers so they are aware of the meanings so proper coding can be applied. Coding should not be mind reading. This would cut down on provider inquiries. This is from slide 19 from an AAPC presentation.

I don't know how you receive your charts but regardless if paper or electronically some EMRs allow for a check the box scenario before allowing you to move on. A few simple questions could lead the provider to the correct category. Coding the same specialty over and over should actually be easy, boring and monotonous not a constant mind reading 🧩.

The link below addresses various coding scenarios for screening, surveillance and diagnostic colonoscopy coding for Medicare and non-Medicare patients with ICD-10-CM, CPT and HCPCS coding. It also has presentation slides. My best wishes to you.

COLONOSCOPY CATEGORIES
 Diagnostic/Therapeutic Colonoscopy: Patient has past and/or presents with gastrointestinal symptoms, polyps, GI disease, iron deficient anemias and/or any other abnormal tests.

 Surveillance/High Risk Screening Colonoscopy: Patient is asymptomatic (no
gastrointestinal symptoms either past or present), has a personal and/or family
history of colon polyps and/or cancer. Patients in this category are required to
undergo colonoscopy surveillance at intervals of every 2-3 years.

 Preventative or Screening Colonoscopy Diagnosis: Patient is asymptomatic (no GI
symptoms past or present), is over the age 50, has no personal or family history of
gastrointestinal disease, colon polyps, and/or cancer. The patient has not had a
colonoscopy in the past 10 years.

** Diagnosis for screening colonoscopy is tied to correct diagnoses when it comes to patient share of cost.


Click to expand...
I completely agree with your comments. I do feel like I'm mind reading. What I need to know is if I should use the diagnoses on the accompanying H&P or just use what's on the Op Note. I just had one a minute ago where patient had EGD w/biopsies and a high-risk screening colonoscopy; however, on the accompanying H&P, there was an extra diagnosis of chronic constipation. It wasn't mentioned on the H&P and I did go back and peek at the referral and the GI office visit to get a clearer picture but I can't use that information. I usually peek at it because it helps me determine if I should send a query. If they stated anywhere they were trying to get to the bottom of the constipation by colonoscopy then I'd have sent a query. In this scenario though I just coded it as a high risk screening and I added the chronic constipation to the final diagnoses. It's such a gray area when they do this, and it should be monotonous and boring as you stated. Argh. When I do query an endo provider I DO put a statement in the query that screening is indicated in the absence of signs/symptoms, if there's a sign/symptom it would be a diagnostic procedure. But, they don't seem to be willing or able to verify the diagnoses on their H&Ps. A couple docs have replied that those diagnoses come from the referring provider, even though the endo doc is the one signing the H&P. I'm unsure what an auditor would say about this issue but I would LOVE to know.
 
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Right now I'm trying to figure out how to code erosive ileitis of the terminal ileum. It codes to Crohn's doesn't it? I noticed there was a note from the endoscopist stating it doesn't appear to be Crohn's after he reviewed the path, the results of which were "TERMINAL ILEUM: Erosive ileitis." How would you code this?
 
nsteinhauser said:
This happens to me all of the time. From the direction of past audits, I can only code what's on the op note.
If it comes back from billing saying "no, this was for BRBPR", then I ask the Gastro doctor to please add that dx to the op note (and it's no longer a screening.)
I'm thinking that the op notes are either partially 'canned' notes. and screening Z12.11 is the default. OR, the doctor is maybe burned out from getting yelled at for "you can't list a diagnosis for a screening colonoscopy" from all those other accounts that WANT the dx to be a screening, that they just say "it's a screeening" on every one.
No help, I know.
Click to expand...
This is helpful info. You stated you can only code what's on the Op Note? Because I was trained to pull everything GI related from the H&P as well. We were audited by FinThrive and they didn't say anything about not using the accompanying H&P. I have to pull any diagnoses, any PMH GI issues, Z87.19, any smoking or history of smoking, any family history of GI issues, diabetes and any diabetes meds because if diabetic they check their blood sugar so there's a glucose lab charged along with the colonoscopy, etc. You were told not to use any of that info?
 
One more scenario that came up, patient is having a colonoscopy and EGD and diagnoses are chronic iron-deficiency anemia, screening colonoscopy, high risk, history of colon polyps, and abdominal bloating. To me, the IDA diagnosis would make the screening colonoscopy a diagnostic but he's saying, the EGD is for the IDA. After the procedure he wants to schedule the patient for capsule endoscopy. So, I'm not sure whether to code it as a screening colonoscopy or a diagnostic. Any input is greatly appreciated.
 
pookergirl said:
Right now I'm trying to figure out how to code erosive ileitis of the terminal ileum. It codes to Crohn's doesn't it? I noticed there was a note from the endoscopist stating it doesn't appear to be Crohn's after he reviewed the path, the results of which were "TERMINAL ILEUM: Erosive ileitis." How would you code this?
Click to expand...
 
Regarding this Dx, I would use K50.018. I tried to upload the image - it says terminal ileitis.
I arrived at that using the following path:

Ileitis>terminal>enteritis>regional>small intestine>with complication>specified complication

I was also trained to go from the Op note first for final Dx, but we could use the other current part of the note like H&P for specificity or additional diagnoses as well as additional procedures with appropriate modifiers if deemed necessary.

Plus, some positions are requiring that additional codes for risk adjustment be pulled along so....
 
pookergirl said:
One more scenario that came up, patient is having a colonoscopy and EGD and diagnoses are chronic iron-deficiency anemia, screening colonoscopy, high risk, history of colon polyps, and abdominal bloating. To me, the IDA diagnosis would make the screening colonoscopy a diagnostic but he's saying, the EGD is for the IDA. After the procedure he wants to schedule the patient for capsule endoscopy. So, I'm not sure whether to code it as a screening colonoscopy or a diagnostic. Any input is greatly appreciated.
Click to expand...
You are correct that it would be a diagnostic colonoscopy. The patient had a history of colon polyps. See below for additional information on other signs or symptoms that could make it a diagnostic colonoscopy.


A colonoscopy is considered screening when:

You’ve had no lower gastrointestinal signs or symptoms before the colonoscopy
No polyps or masses are found during the colonoscopy
There’s no family history of polyps or colon cancer
You have no history of polyps or colon cancer
Diagnostic Colonoscopy
Unlike a screening colonoscopy, you may be required to pay a deductible or coinsurance for a diagnostic colonoscopy, according to your insurance policy.

A colonoscopy is considered diagnostic when you’ve had:

Signs or symptoms in the lower gastrointestinal tract noted in your medical record before the procedure, including:
Abdominal pain that doesn’t improve
Anemia
Change in bowel habits
Constipation
Diarrhea
Rectal bleeding
Blood in the stool
Polyps within the past 10 years
A positive stool-based test or CT colonography and require a follow-up colonoscopy
 
pookergirl said:
This is helpful info. You stated you can only code what's on the Op Note? Because I was trained to pull everything GI related from the H&P as well. We were audited by FinThrive and they didn't say anything about not using the accompanying H&P. I have to pull any diagnoses, any PMH GI issues, Z87.19, any smoking or history of smoking, any family history of GI issues, diabetes and any diabetes meds because if diabetic they check their blood sugar so there's a glucose lab charged along with the colonoscopy, etc. You were told not to use any of that info?
Click to expand...
Back to this question, we are allowed to pull from the op note AND the MDA's (anesthesiologist's) exam the day of the procedure. But no on the H+P. Maybe it depends on what company audits you. How's that for consistency? However, sometimes the anesthesiology note is a copy and paste of every diagnosis the patient has ever had during the 10, 20, 30 years, etc., they've been seen by this hospital. Problem: the "diarrhea" in the MDA's list may have been from a visit 15 years ago and has since resolved. So we have to stick with the op note in most cases unless the MDA summarizes "current issues" at the end of his or her exam. But DM is always listed in the MDA note if there is DM, so yes we always pull that because of the glucose check.
In answer to your other question, the ida is going to flag the 'screening' colon as a diagnostic in the payer's adjudication software, you're right. I don't know what to do here. Without any other guidance, you have to use the ida if that's the only dx given. Unless anyone else has ideas?
 
mikhaila said:
You are correct that it would be a diagnostic colonoscopy. The patient had a history of colon polyps. See below for additional information on other signs or symptoms that could make it a diagnostic colonoscopy.


A colonoscopy is considered screening when:

You’ve had no lower gastrointestinal signs or symptoms before the colonoscopy
No polyps or masses are found during the colonoscopy
There’s no family history of polyps or colon cancer
You have no history of polyps or colon cancer
Diagnostic Colonoscopy
Unlike a screening colonoscopy, you may be required to pay a deductible or coinsurance for a diagnostic colonoscopy, according to your insurance policy.

A colonoscopy is considered diagnostic when you’ve had:

Signs or symptoms in the lower gastrointestinal tract noted in your medical record before the procedure, including:
Abdominal pain that doesn’t improve
Anemia
Change in bowel habits
Constipation
Diarrhea
Rectal bleeding
Blood in the stool
Polyps within the past 10 years
A positive stool-based test or CT colonography and require a follow-up colonoscopy
Click to expand...
I believe the information you posted above from Coding Intel regarding screening colonoscopies is out of date and no longer correct. If the patient has a history of colon polyps, hx of colon cancer, family hx of colon cancer in a first-degree relative (or according to some insurance a 2nd degree relative also applies) or anything on this list below, then it's a high-risk screening, but still a screening, so Z12.11 should be the first listed diagnosis:

Medicare beneficiaries without high risk factors are eligible for screening colonoscopy every 10 years. Beneficiaries at high risk for developing colorectal cancer are eligible once every 24 months. Medicare considers an individual at high risk for developing colorectal cancer as one who has one or more of the following:
  • A close relative (sibling, parent or child) who has had colorectal cancer or an adenomatous polyp.
  • A family history of familial adenomatous polyposis.
  • A family history of hereditary nonpolyposis colorectal cancer.
  • A personal history of adenomatous polyps.
  • A personal history of colorectal cancer.
  • Inflammatory bowel disease, including Crohn’s disease and ulcerative colitis.
Source: https://gastro.org/practice-resources/reimbursement/coding/coding-faq-screening-colonoscopy/

The last part of the information from Coding Intel seems correct from everything I've researched, but still I'm getting snagged in those gray areas where the endoscopist will state it's a screening colonoscopy but then state patient has iron deficiency anemia as well. Sometimes I will go into the chart and look at the referral to see how, and when, it was ordered. And yes, sometimes they will include diagnoses on their documentation that is YEARS old and no longer applicable, it just keeps getting carried over. That is frustrating. Here's a scenario I see, where the accompanying H&P diagnosis will be crohn's with rectal bleeding or UC with rectal bleeding or intestinal obstruction even but the Op Note preop diagnosis will only state Crohn's or ulcerative colitis. No mention of obstruction or bleeding so like someone stated above, that puts me in a position of having to make a choice that shouldn't be my choice to make.
 
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mikhaila said:
Regarding this Dx, I would use K50.018. I tried to upload the image - it says terminal ileitis.
I arrived at that using the following path:

Ileitis>terminal>enteritis>regional>small intestine>with complication>specified complication

I was also trained to go from the Op note first for final Dx, but we could use the other current part of the note like H&P for specificity or additional diagnoses as well as additional procedures with appropriate modifiers if deemed necessary.

Plus, some positions are requiring that additional codes for risk adjustment be pulled along so....
Click to expand...
Yep, that's exactly what it defaults to, but then like I said, doc created a note to the patient stating it doesn't appear to be Crohn's. Which I know I can't use a note to patient but it makes it more confusing that he stated that.
 
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