Wiki Scheduled Colorectal Screening with signs and symptoms

[maddymoo]

If a patient is scheduled for a colorectal screening and upon arrival tells the physician that he/she has had rectal bleeding or chronic diarrhea, should one of the diagnosis codes be V76.51 with the signs and symptoms? If biopsies are taken should a PT modifier be appended? The ICD-9 screening guidelines state, "The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test". Since the patient was sent for a screening but notified the performing physician of some sign or symptom, should the V code be dropped or should it be left on since that was the original intention for the procedure? I guess I'm just used to not billing the screening diagnostic code if there is a sign or symptom due to the ICD-9 guidelines, but this is a slightly different scenario. Thanks for your help.

 

[mitchellde]

The thing to check here is if the symptoms expressed by the patient are current symptoms or do they come from =questioning as to whether the patient has had these problems in their history. If they are current aggravating symptoms then perhaps the test was incorrectly ordered as a screening as this is diagnostic. But if the patient is mere relying that these things have occured at some point then it is still screening as these are history issues and not current symptoms.

 

[maddymoo]

That makes sense. Thank you so much for your response!