Wiki Coding by intent or what is actually dictated

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Nancy Jones

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Good morning. I need some help. One of my GI docs did a colonoscopy in a hospital setting and his reasons for doing the procedure state: A 57 year-old patient who presents with anemia, colonoscopy now to evaluate for possible neoplastic process of the colon. The hospital coded the diagnosis as V76.51 which is screening. I discussed this with the coder and she stated that we could see that his intent was that it be a screening. Anemia unspecified does not cover a colonoscopy, but because it is dictated on the operative report several of us in the office felt we should use it. Could someone please tell me do we code from intent or do we use the diagnosis' listed on the operative report?

Thanks for the help!!
Nancy Jones, CPC
 
You cannot code from intent. This appears from what you have stated to be a diagnostic exam based on the symptom of anemia. If the finding is malignancy then you use that dx code. However if the provider did not find anything of consequence then you can use V71.1 for observation and evaluation for suspected malignant neoplasm not found as the first listed code and the anemia secondary.
 
Thank you for the help. I could find nothing stating that we could code from intent but the other coder is a CPC as well and she was adamant that we could code from intent. I just wanted to make certain that I was coding correctly.

Nancy Jones, CPC
 
Yes V71.1 can be used in any setting and is first listed only allowed, but you must have a path report that shows the malignancy was NOT the finding.
 
so if the colonoscopy is done for unspecified anemia, but prov doesn't specifically state that a malignancy is suspected, and nothing else is found, V71.1 is appropriate?
 
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