Coach Jennifer: Yey! We had somebody was wondering about preventive and diagnostic colonoscopies.
Q: I was wondering if you can assist clarification on preventative versus diagnostic for outpatient hospital.
A: There are certain rules that you follow when we’re dealing with the colonoscopies. So now we all are familiar with the nice little chart that’s put in the CPT manual, which is very beneficial. Tag it, flag it somehow in your CPT book, so if you’re studying you can go straight to that because we know it will come up. But that is how to code specifically that colonoscopy if it doesn’t get to a certain point, or if it get to a certain point, what code is it, what do you use for modifiers and such. Anyways, this person just needed some clarification for outpatient hospital procedure.
A preventive - they know that that’s the doctor, you’re documenting the H&P, the patient has no symptoms and so they said, “OK. We’ll do a screening.” That’s preventive. Diagnostic - OK, there’s something documented that says they have blood in the stool or something like that, “so we need to go in there.” That’s diagnostic, we need to diagnose it and look at it and see what’s wrong. That’s diagnostic.
What if they say the patient has rectal bleeding, but the treatment plan is to do a screening with a screening ICD-10 code is their diagnosis? So, the case, wound up encoded with 45380 with a 33 modifier (we’re going to go over all this) and their diagnosis was the screening. But their question as well if the doctor said there was a problem, they had rectal bleeding, why is it a screening? Should it be diagnostic or should it be the preventive screening?
We’ll break this down a little bit. According to the American Gastroenterological Association, the screening test is provided when that patient has no signs or symptoms. You’re 58, time for colonoscopy, you’re not having any problems, so probably everything is OK but we need to do it, so we’re looking at the screening then. We want to make sure there are no problems; we’re screening the patient to see if there’s anything wrong.
Even if they found a polyp or some kind of benign or malignant or some kind of cancer in there, some kind of problem that they’ve found during that test, the intent doesn’t change. It started as a screening, that’s the codes we’re going to use even though we found something while we were there, so the screening diagnosis is still going to be primary and then that polyp or whatever is going to be secondary.
A diagnostic is performed according to the AGA, when there’s an abnormal finding, a sign, or a symptom. It could be abdominal pain, it could be bleeding or diarrhea. Anemia is another reason why they would do a diagnostic colonoscopy. On their website of AGA, they had some commonly asked questions and answers. I thought, OK I’m going to snag one of these: what if the patient or their referring physician who called and said “OK, I need to get this patient in for a colonoscopy.”
They said, “Yup. I have no symptoms.” Or you talk to the patient, they said, “Yeah, I have no symptoms.” But then they come in the office and they say, “Oh, yeah, but I had problems in the past, I don’t have any now.” At that point, it becomes the physician’s decision. If those symptoms or whatever they had in the past or what might have gone on previously is going to justify whether they are going to do a screening or a diagnostic procedure. That’s a little tricky and that’s the physician who’s going to make that decision once they’re there talking to the patient.
What if they have polyps that were discovered on a past screening, however, when they come in now they don’t have symptoms? So, that patient is asymptomatic; they don’t have any symptoms, it’s still considered a screening even though the last time they had one five years ago or whatever. They said, “Yup! We found a problem but it is OK. It’s going to go away” or whatever. They don’t have any symptoms or signs going on right now five years later, so it’s again just a screening.
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