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Gastroenterology Coding Alert

READER QUESTIONS:

No Symptom Present, No 799.9

Published on Sun Jun 12, 2005

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.

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