Wiki Colonoscopy Question

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amowens854

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Newport, NC
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The following is typical operative note documentation by our physicians for patients returning for surveillance colonoscopy (24 months or greater) when no pathology found on current colonoscopy:
Preoperative Dx: personal history of colon polyp,
Postoperative Dx: personal history of colon polyp
Procedure: COLONOSCOPY.
The diagnosis and timeline fit Medicare and other insurance requirements for high risk screening colonoscopy (G0105).
My question is: MUST the physician document the procedure as SCREENING colonoscopy in order to meet coding guidelines and assign G0105 to this procedure?
If you could point me to specific guidance I would appreciate it, as this is needed as evidence to establish workflow protocol.
 
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Yes, and the ICD-10 code used : Z12.11 and Z12.12
COLORECTAL CANCER SCREENING
Screenings are performed to diagnose colorectal cancer or to determine a beneficiary’s risk for developing colorectal cancer. Colorectal cancer screening may consist of several different screening services to test for polyps or colorectal cancer.
Remember that the document should support the service render. It would not be medically necessary or appropriate to document a service that is not warrant.

Check out the
Preventive Services Guide for Colorectal Cancer Screening from CMS below:

 
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