tci General Surgery Coding Alert - 2022 Issue Q3

Reader Questions: Convert This Screening Colonoscopy to Diagnostic? Not So Fast.

Question: During a screening colonoscopy, the surgeon documented finding hemorrhoids, but did document any work to treat the condition. Should we code this as a diagnostic colonoscopy because of the abnormal findings? Washington Subscriber Answer: No, you should not code this as a diagnostic colonoscopy in this case, assuming you have documentation that the ordering physician requested a medically-appropriate screening colonoscopy. Here’s why: During a screening procedure, the surgeon should document incidental findings and you should code any appropriate diagnosis. But if the findings don’t change the fundamental nature of the procedure, you should not change the...

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