Wiki Need opinions on colonoscopy coding......

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sheardmd

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I work for a group of surgeons that also see patients in neighboring smaller communities in the hospital outpatient departments. We had a patient that we saw in one of these outpatient clinics for abd pain/gallbladder polyps. Our doctor recommended some rx and prn follow up. In the intervening week, his family physician called and scheduled him for a colonoscopy with our physician at this satellite hospital. Reason for colonoscopy was the abd pain. Abd pain is not a covered diagnosis on the LCD and the hospital did not have him sign an ABN. The patient just had a screening colonoscopy in 2008 and has no personal or family history that would pay for one sooner. Very mild focal sigmoid diverticular disease that was not biopsied was an incidental finding on the colonoscopy, but there were no other findings. In my opinion we should not be able to code this colonoscopy to the 562.10 findings since we did not have a payable reason for doing the procedure. I think that this should be sent in as 1) 789.00 2) 562.10, but I am aware that Medicare will not pay it like that. The hospital disagrees and has already been paid on the 562.10 primary code that they used. Would love to hear other opinions on this matter.

Thanks,
 
The End doesn't justify the means

The indication of abd pain is not medically necessary according to medicare. So no matter what you find during the procedure, the indication was abd pain, and it is not covered. Simply listing the diverticulosis first in order to get your claim paid would not be appropriate. The claim should be submitted with the abd pain as the indication.
That being said - you may have difficulties getting management or your physician to agree with you on that one.
 
I disagree.
The only time you bill the symptoms as the diagnosis is when you cannot establish a definitive diagnosis. Since diverticulosis could have been the reason for the pain - even though it is an incidental finding, this is what your diagnosis should be on the claim - not the symptom of abdominal pain.

I agree that it was in poor judgement for the physician to just order a colonoscopy, as the patient could have had diverticulitis, ( hopefully imaging of some sort and blood work was done to rule this out.) but, for all we know his physician may have seen the patient last week for change in bowel habits and failed to share that information.

Here is medicare's rule:

For outpatient claims, providers report the full ICD-9-CM code for the diagnosis shown to be chiefly responsible for the outpatient services in the appropriate FL. For instance, if a patient is seen on an outpatient basis for an evaluation of a symptom (e.g., cough) for which a definitive diagnosis is not made, the symptom is reported (786.2). If, during the course of the outpatient evaluation and treatment, a definitive diagnosis is made (e.g., acute bronchitis), the definitive diagnosis is reported (466.0). If the patient arrives at the hospital
Good Luck
 
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