Wiki "Colon scrn" with long term diarrhea and fecal incontenence

[jfolz]

I am a relatively new coder for an outpatient facility.
YESTERDAY, I had a note returned to me stating that I should have left v76.51 as the primary dx for a patient that presented with multiple digestive symptoms, including long-standing diarrhea and abdominal pain. I was corrected by a more senior (and much more highly educated) coder within the organization and told that because the patient had a previous dx of IBS years back, the diarrhea and abdominal pain should be overlooked as the norm for this patient and that the primary dx in this case should have been v76.51. I initially didn't see the IBS dx in the patients chart...and I suppose that I understand that in this case. (However, everything I can find online and in print is telling me that chronic diarrhea automatically excludes you from using v76.51..?)
TODAY I have the following op note to code and I have no clue now what to do:
Preop dx- need for screening colonoscopy, mild to moderate anal incontenence
post-op dx-same as above plus diverticulosis
procedure- screening colon. w/ mucosal biopsies to rule out microscopic colitis
path- came back benign colononic mucosa with no sig. histopathologic change, neg for acute and chronic colitis
indications- pt has a long history of loose stool, 1 to 3 a day and is now having at least 1 or more accidents or stool per week. (MD never says the word "chronic" only long history)
Procedure-Colonoscopy is performed, including noting during an included digital rectal exam that the patient demonstrated "very minimal extremely lax sphincter muscle tone". "As the scope was being withdrawn, I did cold biopsies from both the right side of the colon in the left side of the colon." There were no growths or abnormalities detected.
Pt indicated to return in 10 years for another screening. Pt will also be referred to an incontenence clinic for further eval and treatment. "Of course, this would include treatment of microscopic colitis should it be discovered on biopsy." (It was not.)
This patient has no mentioned known diagnoses like IBS or any other reason I can see in the limited history dictation from the office that I should look the other way from this diarrhea and incontence. On one hand, I don't feel that the dr would have done this exam and biopsies without the earlier dx of the diarrhea and incontenence because other than the finding of the lax sphincter, there were no other abnormalities reported. On the other hand, I don't have any documentation of why the patient presented to the appointment...I don't know if she normally tolerates these symptoms and got a colon screening reminder or if the development of the fecal incontence brought her in and then then it was noticed she qualified for a screening. (PT is 76, on Medicare and hasn't had one since 2003.)
I don't want to cause a problem with my supervisor but I also want to do the job as I should be, without causing undue billing issues for a patient. I do know that the office believes they are sending the pt for a screening and I'm sure the told the patient that it would be a covered screening so if I go against that I will need backup for my logic.
ANY help or perspective on this issue would be greatly appreciated!!

 

[MAult142]

This is a thorny issue and you're going to run into it a lot.

If the doctor has scoped the patient before and the office sent them a recall letter telling them it was time to schedule their screening again, then the reason for the colonoscopy is screening. The most common reason I've found for doctors to post both screening and symptoms as indications is when the doc talks to the patient right before a procedure that was scheduled as screening and the patient mentions to the doc that they had some diarrhea or another symptom. That symptom wasn't the reason the procedure was scheduled, so it is not the reason for the colonoscopy.

Whenever the doctor documents both screening and symptoms as indications, we have to find out if the doctor feels the symptoms were incidental and it's still a screening or if the symptoms are serious enough to trump the screening indication entirely. After all, not every bout of diarrhea warrants a colonoscopy.

It is matter of documentation. If the doctor feels that the symptom is not serious enough to be the primary reason then he needs to document the symptom as incidental or not related to the procedure. If he doesn't do that, then we have to query the doc and have him amend the note before we'll post the charge.

When the patient has an office visit and they're having a lower GI symptom that can be a reason for a colonoscopy and the patient also happens to be old enough to have a screening, it can be a nightmare. The doc feels like he's killing two birds with one stone. The question becomes, would he have ordered the colonoscopy if the patient was having the same symptom with the same severity and wasn't old enough for a screening yet....

Again, it's a matter of documentation. We try to get the providers to put their MDM in the note so that's it's obvious to an outside auditor whether or not the colonoscopy was ordered b/c they're over 50 or b/c they're having diarrhea but it's an uphill battle.

So the short answer to my very long-winded reply, is that you need to ask the doctor. It might sound to you like the only reason he would have ordered the colonosocpy is because of the incontinence, but only the doctor can make that determination.

And try to work with the office, your supervisor, and the docs to get a system in place so that you don't have to query them every single time. Our office sends a copy of our scheduling form to the facility so the facility will know the reason why the procedure was originally scheduled and then we've groomed the doctors to document if the symptom was incidental the first time around. They'll eventually get irritated enough by your queries to want to post it right the first time.