Oncology & Hematology Coding Alert

Question: A patient came into our office because they have a family history of colon cancer and they wanted the provider to order a screening colonoscopy. There was no other chief complaint. The provider performed an exam and then ordered the procedure. The A/P just stated “Screening colonoscopy, family hx of colon ca.”

The provider used 99213 for this, but I disagree. To me, 99202-99215 are specifically for problem-oriented visits. Shouldn’t there be a chief complaint here or is family history of colon cancer considered a chief complaint? I personally feel that this should have been a preventive visit instead.

AAPC Forum Participant

Answer: In this case, you are absolutely correct, and you would not use 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making …) or any other office/ outpatient evaluation and management (E/M) code for that matter.

The reason, as you also correctly point out, is that there is no chief complaint. A patient presenting solely for the purpose of consulting prior to a screening colonoscopy most likely does not have a chief complaint to report. In other words, a family history of cancer does not meet the medical necessity for an E/M service.

In this situation, the most appropriate way to document the consult, if your payer accepts it, is S0285 (Colonoscopy consultation performed prior to a screening colonoscopy procedure). This HCPCS Level II code is not covered by Medicare and other payer policies on this code do differ, so be sure to check with them before using the code.