The physician dictated screening colonoscopy and incidental constipation as a pre op diagnosis. I queried the physician's office, the physician responded to bill as a screening, incidental findings should not keep us from billing a screening. Every article I have found states that any symptom indicated in the medical record will change the screening to a diagnostic exam. I cannot find anything related to an incidental symptom. Any help is greatly appreciated! Thank you
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki Screening colonoscopies with Incidental symptoms
- Thread starter bethh05
- Start date
GaPeach77
Guru
I agree with the physician, unless any type of removal of waste was performed, a preventive screening code is correct. If a polyp was found and removed during the colonoscopy, then for a Medicare patient a PT modifier is required for a screening that turns into a procedure. Not sure that constipation requires a procedure and the screening code is correct.
The question is about pre op diagnosis, I am trying to determine whether an incidental pre op diagnosis should be considered a symptom? The physician is stating that because it is incidental, I guess it should not be considered, but it is still indicated in the medical record. Constipation is not a payable diagnosis, but it is still a symptom. If you see the 4th paragraph in the article, it states this.
http://digestivecarephysicians.com/client_files/file/scrngvsdiagcolon.pdf
Once a symptom has been dictated it is not considered a screening. Here is another article regarding coding colonoscopies, if you are billing screenings when symptoms are dictated that is incorrect.
http://www.beckersasc.com/asc-codin...rs-guide-to-surgery-center-colonoscopies.html
http://digestivecarephysicians.com/client_files/file/scrngvsdiagcolon.pdf
Once a symptom has been dictated it is not considered a screening. Here is another article regarding coding colonoscopies, if you are billing screenings when symptoms are dictated that is incorrect.
http://www.beckersasc.com/asc-codin...rs-guide-to-surgery-center-colonoscopies.html
Last edited:
mitchellde
True Blue
I would not consider the constipation as a symptom unless it is documented that the patient specifically presented to the office with constipation as the complaint. Just because the patient responded affirmative to a question have you had constipation does make it incidental and not rooted. So it really depends on the note and how the issue was brought up.
syllingk
Guest
I agree that is depends on the context of the constipation. Patient could be on chronic pain meds and have chronic constipation but still qualify just like if they have a component of diarrhea contributed to a med like Metformin and it is not a new change for them.