# screening vs diagnostic



## kjarrells (Aug 31, 2011)

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.


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## sandy5 (Aug 31, 2011)

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


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## Jamie Dezenzo (Aug 31, 2011)

agree with Sandy5


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## syllingk (Oct 14, 2011)

I say we send all questions like this straight to ObamaCare


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## nsteinhauser (Oct 21, 2011)

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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## Tracey Thompson (Nov 4, 2011)

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.


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## coachlang3 (Nov 4, 2011)

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.


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## coachlang3 (Nov 8, 2011)

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.


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## CCMongillo (Nov 17, 2011)

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.


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## bdurbin (Dec 2, 2011)

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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## Coder_Rick (Dec 5, 2011)

*Screening vs Colonoscopy...*

I too have a similar situation where a 51 yr old female PT was referred to my Dr by her physician for bloating, cramps and abdominal pain relieved by bm or flatus. My Dr performed the colonoscopy to check for potential problems and the PT having a family Hx. findings were unremarkable other than some hemmoroids. She uses a commercial payer which does Preventative Care Svcs and PT believes to be entitled to 100%. ( they only paid for the colonoscopy)

I know The Payer lists the procedure, And so I take it that it wouldn't be preventative but a diagnostic screening, but as a new coder I am somewhat confused, as to which is what after reading policies and protocols which I'm not sure about. Is there (1) an actual source that I can access? (2) how should this be coded? (what is the real deal?)

Imput would be appreciated as PT is Rather upset!


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## coachlang3 (Dec 5, 2011)

Depends on why your doctor actually did the procedure.

Did he do the procedure because of the abd pain and cramping or did he do the procedure ebcause the pt needed a CCS?

If the pt was being seen for the abd pain it is not even a diagnostic screening it is just a diagnostic colonoscopy.

The way you wrote it I would code it as a 45378 for the cpt and 789.00 and 787.3 for dx.

What did the doctors procedure note state for the indication?


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## Coder_Rick (Dec 5, 2011)

coachlang3 said:


> Depends on why your doctor actually did the procedure.
> 
> Did he do the procedure because of the abd pain and cramping or did he do the procedure ebcause the pt needed a CCS?
> 
> ...



The colonoscopy was done because of the abd pain and cramping also that the PT has a family Hx for colonrectal cancer.


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## losborn (Dec 5, 2011)

*Gratuitous commment*



syllingk said:


> I say we send all questions like this straight to ObamaCare



The guidelines are not part of PPACA; they are part of appropriate screening procedures for cancer.  Their adoption pre-dates PPACA.

Please keep politics out of this Forum.

Lin


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## mitchellde (Dec 5, 2011)

Coder_Rick said:


> I too have a similar situation where a 51 yr old female PT was referred to my Dr by her physician for bloating, cramps and abdominal pain relieved by bm or flatus. My Dr performed the colonoscopy to check for potential problems and the PT having a family Hx. findings were unremarkable other than some hemmoroids. She uses a commercial payer which does Preventative Care Svcs and PT believes to be entitled to 100%. ( they only paid for the colonoscopy)
> 
> I know The Payer lists the procedure, And so I take it that it wouldn't be preventative but a diagnostic screening, but as a new coder I am somewhat confused, as to which is what after reading policies and protocols which I'm not sure about. Is there (1) an actual source that I can access? (2) how should this be coded? (what is the real deal?)
> 
> Imput would be appreciated as PT is Rather upset!



The guidelines for screening are clear, the patient must be asymptomatic for a test to be a screening.  The phrase diagnostic screening is incorrect, there is no such thing, a procedure is either diagnostic due to a diagnosis or presenting symptoms, or it is screening due to a pre determined criteria such as age, and the patient is asymptomatic.


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## Coder_Rick (Dec 5, 2011)

Thanks for clearing things up!


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## njwanucha (Dec 6, 2011)

Here's another question. We have situation where the doctor's order says "low hemoglobin" and in the Op Note he also refers to anemia. Would you consider this a diagnostic colonoscopy since there may be some other cause of anemia?


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## coachlang3 (Dec 6, 2011)

njwanucha said:


> Here's another question. We have situation where the doctor's order says "low hemoglobin" and in the Op Note he also refers to anemia. Would you consider this a diagnostic colonoscopy since there may be some other cause of anemia?




What is the actual indication for the procedure itself?  Anemia?

Many times the doctor might do an EGD due to upper gi symptoms such as anemia but they have no reason to suspect lower gi symptoms so the colon is a screening and they do an EGD for the upper GI symptoms.

Tough call.


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