Wiki coding for colonoscopy which is mainly for screening purposes

[nannie23]

our physician schedules a screening/preventive colonoscopy for a patient. The hospital orders/registration form states procedure as screening colonoscopy and history and physical dictated by the physician states colonoscopy to be done for screening purposes but the patient may have had occasional rectal bleeding probably from hemorrhoids but not a significant problem to the patient. Does the hospital coders have the right to post the colonoscopy as a diagnostic procedure rather than preventive due to the mention of the occasional bleeding

 

[llhogeland]

Screening CSP

Yes, unfortunately! In order to be a screening, the patient has to be asymptomatic! Hemorrhoids and rectal bleeding are both symptoms which nullify the screening. If it is truly to be a screening, your providers need to be educated that any symptom listed will cause it to not be a screening. If the provider considers the rectal bleeding to be incidental, then it should be left off of the procedure note entirely! If it is a true symptom, and part of the reason for the screening, then the provider should add it in the note and the patient needs educated that symptoms will nullify the screening. Now, on a side note.....if occasional bleeding was mentioned to the provider at an office visit and he notes in the HPI the incidental bleeding that he thinks may be from hemorrhoids, but he does not add it as a diagnosis on the visit since it is not a regular or current problem and he then finds the hemorrhoids in the CSP, that would still be a screening. I know it can be confusing, but does that make sense?