Gastroenterology Coding Alert

Question: We're having trouble reporting our screening colonoscopies lately and could use some clarification. An asymptomatic patient comes to the office for his checkup prior to a screening colonoscopy, and the physician provides a level-two E/M service before sending the patient home. What diagnosis and CPT codes would we use? Someone in a coding-specific Internet chat room told me to use 799.9 (Other unknown and unspecified cause), but I don't believe that's correct.


Ohio Subscriber  
Answer: Code 799.9 implies that there is a symptom present, but the gastroenterologist cannot pinpoint it. So if the patient was truly asymptomatic, you should not use 799.9. Instead, you should:
   report 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these three key components: an expanded    problem-focused history; an expanded problem-focused examination; and straightforward medical    decision-making) for the visit if it was a new patient.
   attach ICD-9 code V72.83 (Special investigations and examinations; other specified preoperative examination) to 99202 to show that the patient 
was asymptomatic.
   report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a problem-focused history; a problem-focused examination; straightforward medical decision-making) for the visit if it was an established patient.
   attach ICD-9 code V72.83 to 99212 to show that the patient was asymptomatic.
 
Note: Medicare may consider this preoperative visit on asymptomatic patients included in the procedure code for screening colonoscopy and therefore deny payment for the E/M service.