mrsseeling
Contributor
I am a physician coder, we are having conflicting information between the physician coders and hospital (RHIT) coders. Here are some of the questions/discussions we are having....it would be appreciated if any answers have information/articles to back them up. Thank you in advance.
We are in Ohio, CGS Medicare.
1. Screening colonoscopy advanced to the sigmoid colon but not beyond. Would this be coded as 45378-53 or 45330? There seems to be confusion when reading the guidelines in the CPT book. It states that diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 or 44388 with modifier 53 and provide appropriate documentation. However, the colonoscopy decision tree says diagnostic procedure-does not reach splenic flexure-45330.
2. patient with occasional constipation, physician states and codes this as a screening colonoscopy (G0121 Z12.11). Since this is occasional is this still a screening?
3. Reason for appointment is diarrhea. HPI states...patient presents for colonoscopy consult. ROS states...Diarrhea: admits. MDM states...screening colonoscopy Z12.11. Would this be a screening or diagnostic? Do you use the ROS information when determining if a colonoscopy is diagnostic or screening?
4. patient with history of colon cancer. We coded this as G0105 and the hospital coders state that since the physician does not state "screening/surveillance" colonoscopy that it should be coded as 45378 diagnostic. Does the physician have to state "screening colonoscopy" or "surveillance colonoscopy" when they dictate the colonoscopy? The LCD for our state says that a patient with a history of colon cancer should be coded as G0105 Z08 Z85.038
5. our physicians use the office visit note from when the colonoscopy was scheduled as the H&P for the colonoscopy, what information do you use for the H&P and orders for the colonoscopy?
We are in Ohio, CGS Medicare.
1. Screening colonoscopy advanced to the sigmoid colon but not beyond. Would this be coded as 45378-53 or 45330? There seems to be confusion when reading the guidelines in the CPT book. It states that diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 or 44388 with modifier 53 and provide appropriate documentation. However, the colonoscopy decision tree says diagnostic procedure-does not reach splenic flexure-45330.
2. patient with occasional constipation, physician states and codes this as a screening colonoscopy (G0121 Z12.11). Since this is occasional is this still a screening?
3. Reason for appointment is diarrhea. HPI states...patient presents for colonoscopy consult. ROS states...Diarrhea: admits. MDM states...screening colonoscopy Z12.11. Would this be a screening or diagnostic? Do you use the ROS information when determining if a colonoscopy is diagnostic or screening?
4. patient with history of colon cancer. We coded this as G0105 and the hospital coders state that since the physician does not state "screening/surveillance" colonoscopy that it should be coded as 45378 diagnostic. Does the physician have to state "screening colonoscopy" or "surveillance colonoscopy" when they dictate the colonoscopy? The LCD for our state says that a patient with a history of colon cancer should be coded as G0105 Z08 Z85.038
5. our physicians use the office visit note from when the colonoscopy was scheduled as the H&P for the colonoscopy, what information do you use for the H&P and orders for the colonoscopy?
