# Symptoms, Documentation, and Screen Colonoscopy



## jmaciulis (Apr 1, 2014)

Hello. I am a newly certified coder who was recently hired at a gastroenterology office. I am looking for advice regarding screen colonoscopy, documentation, and symptoms.

I know we can not code a screening if the patient is evaluated for symptoms. The problem I am running into is that the patient is seen in our office by the NP for something like epigastric pain and she orders an EGD for symptoms and a screen colonoscopy since they are of age and overdue. Both procedures are done at the same time by the physician. The pre-op dx is 789.06 and V76.51. The NP stated in her encounter note that the EGD is for the epigastric pain and the colonoscopy is a screen. Is this proper documentation or will this trigger as being a dx colonoscopy for symptoms?

Example:

Patient is referred for consultation to evaluate 1 - 2 year history epigastric pain, diarrhea, recently worsening symptoms.  Mid abdominal pain, worse in the early morning, also heartburn. Also "runny" stools 3 - 4 times.day with urgency.  Occasionally dark color.  No bright red blood. Has taken pepto bisomol occasionally for diarrhea.  Dietary intake is somewhat irregular.  Denies dysphagia, odynophagia, nausea, emesis, hematemesis, chills, fever, hematochezia.

Assessment:  

50 yo male with GERD, epigastric pain, diarrhea; *due for age-related screen* 
Plan:  

EGD scheduled - r/o PUD, h. Pylori, other UGI pathology
Colonoscopy scheduled



I also am wondering what to do when a patient states they have a symptom like (obviously colon related) diarrhea. The provider will add that to the dx, but document that they are ordering a colonoscopy only as a screen and not to evaluate for the diarrhea. Will this stand up? The pre-op dx only lists V76.51, but I am concerned about the EM visit before the procedure. 

Basically my question is, are patients allowed to have a screen even if they have symptoms, as long as the doctor documents that they are not evaluating for the symptoms but just ordering a screen due to age/family history?

I really appreciate any advice. Thank you in advance.


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## dputney (Apr 1, 2014)

A screening colonoscopy is just that a screening and the patient has no symptoms. Based on the info that you provided, this patient had symptoms
diarrhea,changes in bowel habit, abdominal pain.  If medical records were to be requested, you might run into a problem.  What did the physician put on the operative report, as you should be coding from that. The ones I worked with in the past would put diarrhea,abd pain screening and I would have to use diarrhea, abd pain.  Patients (and some physicians) have a hard time understanding this since most screening are paid at 100%, but with those symptoms it will not be a screening.


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## kimbur511 (Apr 1, 2014)

*Screening dx*

As long as you are using a screening CPT with the screening diagnosis of V76.51 you will be fine. If the Dr is saying that he is doing it for age, then that is what you want to code. Patient's symptoms may have nothing to do with the procedure and you want to follow your physician's documentation.
Now if the screening turns to a diagnostic study due to finding polyps, etc then you need to change to a diagnostic dx code. 

BTW - the dx coding varies with Medicare and senior plans.
If you need some more assistance feel free to send me a private message and I can help you out.


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## mitchellde (Apr 1, 2014)

I disagree, the dx coding does not vary with plan. it varies by patient.  The diagnosis is the patient's not the plans.  if the patient is documented as actively symptomatic then it cannot be a screening.  the coding guidelines will tell you the dx coding rules.


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## jmaciulis (Apr 2, 2014)

I agree that the patient definitely has symptoms. But my question is is the doctor able to just do a colonoscopy as a screening and disregard the symptoms? He is not basing his decision to do one on symptoms, just on age and family history. The op report lists the pre-op dx as V76.51. I realize if something is found during the colonoscopy that changes things, but in this case there were no abnormal findings. 

It was during the consult visit with the Nurse Practioner before the procedure that the patient mentioned abdominal pain, diarrhea, etc.


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## mitchellde (Apr 2, 2014)

Were the symptoms discussed prior to the decision to perform the colonoscopy?  If so then it is diagnostic.  If the screening was scheduled prior to the discussion with the NP and the patient is relating only history of having had these things then it is screening.


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## MAult142 (Apr 4, 2014)

We run into both these issues frequently.  

Second one first: For patients we've scoped before, we send out recall letters when it's time for them to be scoped again asking them to call our office to schedule.  So if right before the procedure they mention to the doctor that they've had some diarrhea or other symptom in the recent past, we usually still code whichever V code applies as primary b/c the reason the procedure was scheduled was for screening or surveillance.  

If a recall letter didn't bring the patient back to our office and the doctor has documented both screening and symptoms as indications, we have to find out if the doctor feels the symptoms were incidental and it's still a screening or if the symptoms are serious enough to trump the screening indication entirely.  After all, not every bout of diarrhea warrants a colonoscopy.  We're trying to get the docs to document whether or not the symptoms are incidental on the op note, which they actually do sometimes.

For the first one, you can do an EGD for symptoms and a colonoscopy for screening at the same time.  Especially if the patient is only having upper GI symptoms and is due for a screening...then there's no grey area.  

But when the patient has an office visit and they're having a lower GI symptom that _can_ be a reason for a colonoscopy and the patient also  _happens_ to be old enough to have a screening, it can be a nightmare.  The doc feels like he's killing two birds with one stone.  The question becomes, would he have ordered the colonoscopy if the patient was having the same symptom and wasn't old enough for a screening yet....

Again, it's a matter of documentation.  We try to get the providers to put their MDM in the note so that's it's obvious to an outside auditor whether or not the colonoscopy was ordered b/c they're over 50 or b/c they're having diarrhea but it's an uphill battle.


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## pscar (May 7, 2014)

I too am a new coder. I have pt that has indication as weight loss for the colonoscopy. Dr states 20 lb weight loss in one year. Pt has Medicare. Last colonoscopy was 10 years ago. When colon performed was "WNL no treatments performed "Will repeat procedure in 10 years. Would this be billed as a screening?


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## EricaR (May 8, 2014)

pscar said:


> I too am a new coder. I have pt that has indication as weight loss for the colonoscopy. Dr states 20 lb weight loss in one year. Pt has Medicare. Last colonoscopy was 10 years ago. When colon performed was "WNL no treatments performed "Will repeat procedure in 10 years. Would this be billed as a screening?



No, this is diagnostic.  You would code 45378 and 783.21. The basis of screening or diagnostic is made prior to the procedure, so just b/c it was WNL doesnt make it a screening since the indication was weight loss.


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## kmordway (May 22, 2014)

Agree completely with MAult142.  We run into this almost every day where a patient is referred for a screening and happens to mention a symptom or two, or with a scenario like yours.  Check out the AGA's website.  In the January 2011 GI Quality & PM News, there was a question about this issue of screening vs diagnostic, and the answer was the physician has to make a clinical decision whether the symptoms justify a diagnostic procedure or whether they are insignificant.  This is reiterated in the May 2013 _Cutting Edge.  _

If the report lists indications of screening and symptoms, I task the provider and ask that exact question.


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