AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2017 Quarter 1; In This Issue
Screening, Surveillance, and Follow-up Colonoscopy
A 55-year-old male underwent screening colonoscopy and a large polyp was found. Due to its size, and the inability of the gastroenterologist to visualize the base of the polyp, it was only partially removed. The pathology confirmed tubulovillous adenoma and the provider recommended a follow-up colonoscopy in three months. How would this encounter be coded? ...
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Article Overview
This article explains guidance from the AHA Central Office on ICD-10 about coding outpatient colonoscopy encounters when a screening exam leads to additional findings or follow-up care. It is aimed at coders, billers, and compliance staff who need to understand the general framework for reporting screening versus other colonoscopy-related encounters under ICD-10-CM, along with the broader context of surveillance and follow-up situations.
Why This Topic Matters
Colonoscopy encounters often involve a mix of screening intent, unexpected findings, and later follow-up recommendations, which can affect diagnosis reporting and claim accuracy. Understanding the scope of this guidance helps support consistent ICD-10-CM code selection for these common outpatient scenarios.
What You Will Learn
- How the article frames screening colonoscopy encounters under ICD-10-CM
- How related findings and pathology are discussed in the context of diagnosis reporting
- How follow-up recommendations are addressed in relation to the original screening encounter
- The general distinction the article draws among screening, surveillance, and follow-up colonoscopy scenarios
Who Should Read This
- Medical coders
- Outpatient billing staff
- Revenue cycle teams
- Compliance professionals
- Healthcare documentation staff
Codes Discussed
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