Health Information Management

Tip: Determine whether a colonoscopy is really a screening procedure

APCs Weekly Monitor, October 9, 2009

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Coding a screening colonoscopy should be relatively straightforward. However, the interpretation of a screening can sidetrack coders.
 
The definition of a colonoscopy screening procedure can differ depending on whom you ask. A coder’s definition may be completely different from a physician’s.
 
A physician might say a screening occurs when he or she encounters a patient who has experienced rectal bleeding with bright red blood on the toilet paper for more than one month and for which the etiology is unknown.
 
However, this would not qualify as a screening colonoscopy from a coding perspective because the patient was symptomatic. A true screening applies only to asymptomatic patients. Examples include patients who are due for a routine colon examination upon reaching 50 years of age or those who return for an exam two years later because of a history of polyps.
 
Review the critical components of the medical record when coding colonoscopies. This will ensure compliance and encourage revenue integrity.
 
This tip was adapted from the article “Coders beware—Is that screening colonoscopy really a screening?” in the October issue of Briefings on APCs.



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