Wiki Screening vs Diagnositic Colo for IBS- feedback please

[AR2728]

Screening vs Diagnositic Colonoscopy for IBS- feedback please

Patient presented to surgeon on 6/18 for IBS issues. Appt scheduled per family physician due to ongoing patient GI complaints. Physician diagnosis IBS constipation type patient to have labs and schedule for colonoscopy. Patient concerned about how scope will be billed and paid. Physician tells patient this will be a screening colonoscopy because she is "due" for her screening. He adds on "screening" colonoscopy diagnosis.

Patient has colonoscopy on 7/1. Physician operative report read screening colonoscopy with hx of constipation. However, physician coder and hospital coder review preoperative notes-including 6/18 visit and determine colonoscopy was scheduled for diagnostic reasons and patient presented for current GI complaints not for screening colonoscopy. Colonoscopy was billed as diagnostic by facility and physician coders. Now patient is calling surgeon office asking nurse why her EOB is processing as diagnostic when nurse and doc told her it would be screening. Nurse informs me of the situation, and I inform her that the patient clearly presented for active GI issues. She argues that physician did not list active issues on the operative report but only screening with hx and physician believes coding should be altered.

I'd love to know how others feel about this situation. This physician feels that if a patient is due for a screening, regardless of what symptoms may bring them to this office, then he can make the decision to bill as screening. However, I believe insurance will clearly view this as fraud. The patient is presenting with issues, the fact they are due is incidental. Please provide me some feedback....I think I'm in for a battle with my surgeon. Again!

 

[AR2728]

I'd love to hear from fellow coders on how they would have coded this scenario or approached this physician.

 

[Janelle926]

I would also love to see how other coders view this. I work for a GI Group and this comes up A LOT! I believe that if a patient is due for a screening colonoscopy then yes i think they "should" get one..... **BUT** if a patient has an issue/problem/symptom/whatever then that MUST be the primary diagnosis on the claim (you can put the screening as secondary) but it will still pay as diagnostic, therefore hitting the patients deductible in most cases. The problem supersedes the screening. I let patients know that they can appeal this with their insurance carrier. (And I have seen some pay)

 

[pamsbill]

IMO, this is definitely not a screening. The physician needs to be educated to not tell someone with symptoms their colonoscopy will be a screening. His or her answer should always be that some insurances have very specific guidelines for what constitutes a screening colonoscopy and that we will submit the claim according to the medical record. S/he should suggest the patient clarify with their insurance company as to their definition of a screening colonoscopy.

What I explain to the patient is, "The insurance company sees the other claim(s) which have been submitted, including other physician's claims. They will see they processed office visits or other claims because of a problem or problems and that we cannot suddenly change course and submit a claim saying there are no problems, just to get the procedure covered in full. This is fraud and we cannot do it. We could be barred from participation with that company, or worse."

 

[jmaciulis]

This comes up a lot for me too, and it is very frustrating and complicated. Personally, I would code it is as diagnostic because the patient was clearly seen for symptoms and those symptoms warrant an evaluation. The guidelines clearly state a screening is for a patient who is "seemingly well." Unless our providers specifically document that the symptom does not need further workup then it is diagnostic.

I have a lot of trouble with this with our IBS/IBD patients who always seem to be having symptoms and also are frequently due for a colonoscopy. Whether that is screening/surveillance/diagnostic my physicians never make clear. If you ask, they will say screening, because to a GI doctor everyone is always due for a screening.

 

[elaine.pulsepoint@icloud.com]

This is a tough one and should be reviewed with the physician as needed. If a patient has known IBS and it is under control and they've never had a screening colonoscopy, they may in fact be eligible for a screening colonoscopy. If however, the patient is seeking diagnostic treatment of the IBS and they present with GI symptoms, a screening on its own would not be supported (the patient presents with symptoms and wants those symptoms treated - that's a diagnostic procedure).

Per the AGA and American Cancer Society, having IBS does not put a person at a higher risk of developing colon cancer: Irritable Bowel Syndrome (IBS) is a chronic functional problem of the gut, usually characterized by patterns of diarrhea and loose stools alternating with constipation. IBS may also be associated with abdominal cramping and pain. **IBS is not associated with an increased risk of developing colorectal cancer.** Patients with IBS have normal life expectancies but **should follow the recommended screening guidelines appropriate to their population.** If your IBS symptoms change from their usual behavior or regular pattern, or if you see blood in your stool, notify your physician and gastroenterologist.

Additionally, CMS states that a diagnostic colonoscopy is **not** considered medically necessary for the following conditions:

1. Chronic, stable, irritable bowel syndrome or chronic abdominal pain. There are unusual exceptions in which colonoscopy may be done to rule out organic disease, especially if symptoms are unresponsive to therapy.

Now that's tricky.

However, if a patient has IBD (irritable bowel disease), they are considered at a higher risk and would qualify for surveillance colonoscopy:

Inflammatory bowel disease (IBD) is a broad term that refers to chronic swelling (inflammation) of the intestines.

People at increased or high risk:

? A personal history of colorectal cancer or adenomatous polyps
? A personal history of inflammatory bowel disease (ulcerative colitis or Crohn's disease)
? A strong family history of colorectal cancer or polyps (see ?Risk factors for colorectal cancer?)
?A known family history of a hereditary colorectal cancer syndrome such as familial adenomatous polyposis (FAP) or hereditary non-polyposis colon cancer (HNPCC)

Resources: ASGE, ACG, CMS.GOV, CANCER.ORG