AR2728
Expert
I would love feedback on whether you feel this should be coded screening or diagnostic because H&P stated occasions of rectal bleeding. My thoughts are screening as the physician is linking the rectal bleed to hemorrhoidal issues, however, hospital side wants to code diagnostic.
Patient sent to General Surgeon for screening colonoscopy. Initial H&P states presents for screening, cleared by primary physician. She also describes occasions of rectal bleeding which will be addressed at the time and if hemorrhoids are found these will be banded.
Patient will be scheduled for screening colonoscopy with polypectomy and biopsies as indicated and certainly we will be addressing any internal hemorrhoids that are found with banding if this is indicated.
Operative report states primary diagnosis: Screening Colonoscopy
Preoperative note: Patient is -- yr old in need of screening colonoscopy and hemorrhoid banding if these are found.
Patient sent to General Surgeon for screening colonoscopy. Initial H&P states presents for screening, cleared by primary physician. She also describes occasions of rectal bleeding which will be addressed at the time and if hemorrhoids are found these will be banded.
Patient will be scheduled for screening colonoscopy with polypectomy and biopsies as indicated and certainly we will be addressing any internal hemorrhoids that are found with banding if this is indicated.
Operative report states primary diagnosis: Screening Colonoscopy
Preoperative note: Patient is -- yr old in need of screening colonoscopy and hemorrhoid banding if these are found.