Oh the screening colonoscopy…I can think of few procedures in surgery that seem so simple and yet create so many questions about proper coding and billing.
One thing I see quite frequently is a colonoscopy documented as a screening but also listing multiple lower GI symptoms like RLQ abdominal pain and rectal bleeding. Many coders have asked me how to code a colonoscopy in this situation – as a screening per what the GI physician listed or as a diagnostic colonoscopy due to symptoms?
The answer to this question can be found in how the ICD-10-CM manual defines a screening. In the ICD-10-CM guidelines, Chapter 21.c.5, screening is defined as follows:
Screening is the testing for disease or disease precursors in seemingly well individuals so that early detection and treatment can be provided for those who test positive for the disease (e.g., screening mammogram). 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.
Based on this guideline, when both screening and lower GI symptoms are documented as indications for the colonoscopy, the case should be coded as a diagnostic colonoscopy. The colonoscopy is not truly a screening if the patient has known lower GI symptoms that could indicate lower GI disease. To truly be considered a screening, the patient should be “seemingly well” (i.e., without known symptoms or disease of the colon).
