Gastroenterology Coding Alert

Question: A 48-year-old patient complaining of chronic heartburn, cough, and cramps was referred to our office for an EGD. Our gastroenterologist also noted “crampy, lower right abdominal pain” as the additional indications in his notes. After the EGD, that confirmed gastroesophageal reflux in the patient, our physician decided to perform a colonoscopy also in addition to the EGD. He noted that he also performed the colonoscopy for screening because the patient was getting close to 50 and colon cancer could be causing the symptoms. He would not have performed the colonoscopy if the patient been younger because the possibility of colon cancer would be lower. The patient has no history of colorectal cancer. How should I code this scenario?

Massachusetts Subscriber

Answer: For the EGD, you would code 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]). You should support the CPT® code with ICD-9 diagnosis code 530.81 (Esophageal reflux). Under ICD-10, the code will be K21.9. For the colonoscopy, you should report code 45378 (Colonoscopy, flexible; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]) with an ICD-9 diagnosis code 789.03 (Abdominal pain,  right lower quadrant). The ICD-10 cross walk for the same code will be R10.31. 

Your question indicates that the patient was not yet 50 so although your physician noted “colonoscopy for screening” that is not the case. You should resist using special code V76.51 (Special screening for malignant neoplasms; colon) as a second diagnosis.  By the way, under ICD-10, the screening code will be represented by Z12.11. The documentation of the office visit should contain the information about the lower right abdominal symptoms.

After looking at your gastroenterologist’s notes, you may be tempted to just code V76.51 because you know that routine screening colonoscopy is covered without deductibles or co-pay under the rules of the Accountable Care Act. However, you have described a patient who presented with a symptom. If the GI performed the colonoscopy based on a presented symptom, you must code the procedure as diagnostic, not screening. Carriers are not required to pay for a colonoscopy performed solely for a screening before the age of 50.