Internal Medicine Coding Alert

Question: How would you code this office visit? Another office refers a 49-year-old patient to our office for an EGD. The patient complains of chronic heartburn, cough, and cramps. After an exam, our physician decides to perform a colonoscopy in addition to the EGD. The EGD confirms the patient has gastroesophageal reflux. The gastroenterologist writes "crampy, lower right abdominal pain" in the indications, but says later she also performed the colonoscopy for screening because the patient was getting close to 50 and colon cancer could be causing the symptoms; had the patient been younger, the doctor would not have performed the colonoscopy because the likelihood of colon cancer would be lower. The patient has no history of colorectal cancer.

Maryland Subscriber

Answer: For the EGD, you'll code 43235 (Upper gastrointestinal endoscopy including esophagus, stomach,and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]). Your diagnosis is 530.81 (Esophageal reflux). You'll code 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) with a symptom of 789.03 (Abdominal pain, lower right quadrant) for the colonoscopy. You'll code V76.51 (Special screening for malignant neoplasms; colon) as a second diagnosis. The documentation of the office visit should contain the information about the lower right abdominal symptoms.

Why not just a screening diagnosis? After your gastroenterologist talks to you, you may be tempted to just code V76.51. But you have a patient who presents with a symptom. If a symptom requires a colonoscopy, you must code the procedure as diagnostic, not screening.

Most carriers will not pay for a colonoscopy performed solely for a screening before the age of 50. Finally, you'll code the appropriate new patient E/M. If the visit happened to occur on the same day as the procedures, then you would attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M to indicate the  hysician's work in determining the need for the colonoscopy.