Primary Care Coding Alert

Question: A patient came in for follow-up on a chronic condition, and the provider noticed the patient was due for a routine colonoscopy. I was told to use Z12.11. I thought this code was only used to report the encounter of the actual procedure. Am I incorrect?

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Answer: You are correct in saying that using Z12.11 (Encounter for screening for malignant neoplasm of colon) is only appropriate if the physician performs the screening at that encounter. This is implied by ICD-10-CM Official Guidelines, Section I.C.21.c.5, which states, “A procedure code is required to confirm that the screening was performed.”

You can further deduce this rationale from this part of the same guideline: “A screening code may be the first-listed code if the reason for the visit is specifically the screening exam. It may also be used as an additional code if the screening is done during an office visit for other health problems.” During the encounter in question, the screening was not the reason for the visit, and the screening was not done during the office visit.

Here’s how to correctly code the encounter.

You’ll want to report the appropriate evaluation and management (E/M) code with the diagnosis code that accurately reflects the chronic condition. You’ll also want to code any long-term treatment, such as Z79.0- (Long term (current) use of anticoagulants and antithrombotics/antiplatelets) and Z51.81 (Encounter for therapeutic drug level monitoring) if applicable.

The nature of the exam might change things, however. As the patient in this case was seeing the PCP for a chronic condition, not a routine wellness checkup, the nature of that chronic condition will have a direct impact on whether the patient needs a screening or a diagnostic colonoscopy. ICD-10 guideline I.C.21.c.5 explains that a screening is performed for the sake of early detection in asymptomatic individuals. Diagnostic testing is done to rule out or confirm a suspected diagnosis because of the presence of certain signs and symptoms.

If the chronic condition is GI in nature, and the practitioner suspects a bigger problem may be developing, you’d code the signs and symptoms, such as R10.30 (Lower abdominal pain, unspecified) or K62.5 (Hemorrhage of anus and rectum). Because of these symptomatic red flags, the clinical need for the test increases, thus changing the recommended colonoscopy from a screening to a diagnostic test. But the procedure code for the colonoscopy, and the encounter code for the test, again wouldn’t be reported until the test was performed.

The bottom line: Coding Z12.11 is only appropriate if the screening is planned and done during that encounter. Code Z12.11 also requires the procedure itself be reported along with the ICD-10 code to confirm the test’s completion. If the chronic condition for which the patient presented could have conceivably prompted the need for a colonoscopy, seek clarification from the provider regarding whether a screening or a diagnostic test is required.