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Answer: Determining whether to code the result of a test or the reason the test was ordered has been a source of controversy for some time. Coding convention requires coding to the highest specificity possible. Therefore, for most payers you should report the definitive diagnosis whenever possible. If the primary diagnosis does not fully explain the signs and symptoms that prompted the test, you may list the signs and symptoms as a secondary diagnosis. In contrast, if the diagnostic test results are normal or do not provide a diagnosis, report the signs and symptoms only.
Perhaps the most problematic diagnostic coding area for gastroenterology coders is screening tests. Medicare has never directly stated whether, when a problem is found during a screening colonoscopy, the procedure remains a screening service or becomes a diagnostic colonoscopy. The Medicare Carriers Manual in section 4180.1 states that if during the course of the screening colonoscopy "a lesion or growth is detected which results in a biopsy or removal of the growth, the appropriate diagnostic procedure classified as a colonoscopy with biopsy or removal should be billed and paid rather than G0105 (Colorectal cancer screening; colonoscopy on individual at high risk)." Therefore, most coding experts recommend reporting the diagnostic procedure linked to the definitive diagnosis whenever a problem is discovered.
For example, a patient presents for a screening colonoscopy (no symptoms reported), but diverticulosis is discovered, which requires control of bleeding. Rather than reporting the screening with G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) or G0105, report the diagnostic colonoscopy with 45382 (Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]). Link the procedure to the primary findings using the diagnosis code for diverticulosis (562.12, Diverticulosis of colon with hemorrhage). Use V76.51 (Special screening for malignant neoplasms; colon) as a secondary code.
In contrast, if the results are normal, report the screening colonoscopy linked to V76.51. |
