Wiki Diagnosis codes for billing Colonoscopy

[ENDOCODER]

Would like an opinion on this. Our doctor did a colonoscopy on Non-Medicare patient. Indication for Colon states change in bowel habit, abdominal pain, and Screening for Colon polyps. Do we as a coder need to have the word "screening" taken off the report as an indication and just state personal hx of polyps? Or can we leave the word screening on report even though we are not billing for a screening. Are we being too picky?? Appreciate your thoughts on this.

 

[mitchellde]

Would like an opinion on this. Our doctor did a colonoscopy on Non-Medicare patient. Indication for Colon states change in bowel habit, abdominal pain, and Screening for Colon polyps. Do we as a coder need to have the word "screening" taken off the report as an indication and just state personal hx of polyps? Or can we leave the word screening on report even though we are not billing for a screening. Are we being too picky?? Appreciate your thoughts on this.

If the patient is symptomatic and the symptoms prompted the provider to order the test, then it cannot be screening, instead of or in addition to. The question is what did the patient state. I have observed patients that present for a screening, and they answer questions from the standard questionnaire that say things like check if you have had any of the following. So they check things like rectal bleeding, abd pain, etc. but they are currently symptom free. Then the provider checks off things like change of bowel habits, and screening. This can only be one or the other and it depends on what the patient came in for.

 

[ENDOCODER]

Thank you. This patient was boarded for signs and symptoms but he also has a history of colon polyps. He was here for a diagnostic colonoscopy. But the doctor still puts indication is a screening with a history of polyps along with the change in bm and ab pain. I feel he should just indicate history of colon polyps and leave out the "Screening" but he refuses to do that.