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Colonoscopy Performed on Patient with History of Colon Polyps
By Judy A. Bielby, MBA, RHIA, CPHQ, CCS
Many questions arise in coding colonoscopy services, particularly when performed on patients with a history of colon polyps. Recently, the following question was posted under the topic, "Screening Colonoscopy," in the Coding Community of Practice (CoP):
“When you code a colonoscopy [for a patient] who has no symptoms, but had a polyp removed several years ago, do you code screening for malignant neoplasm or follow-up after surgery?”
The purpose of this article is to describe the difference between a screening colonoscopy and a surveillance colonoscopy. This article also emphasizes the importance of reporting codes based on documentation by the provider.
According to the ICD-9-CM Official Guidelines for Coding and Reporting, “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.”1 One method of screening for colorectal cancer is the performance of screening colonoscopy. This procedure allows the physician to closely visualize the entire colon and rectum and look for signs of polyps or cancer.
Risk Factors for Colon Cancer
A review of the literature shows many sources which indicate screening colonoscopy should be performed on people beginning at age 50 if they are at average risk for colon cancer. Medicare considers a person at high risk of developing colorectal cancer if a person has one or more of the following risk factors:
• A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp;
• A family history of familial adenomatous polyposis
• A family history of hereditary nonpolyposis colorectal cancer
• A personal history of adenomatous polyps
• A personal history of colorectal cancer; or
• A personal history of inflammatory bowel disease, including Crohn’s disease and ulcerative colitis.2
It is interesting to note that Medicare includes a personal history of adenomatous polyps or colorectal cancer as higher-risk factors for developing colorectal cancer. This is consistent with other literature as well. In the scenario where a patient with a history of colon polyps underwent a colonoscopy, absent signs and symptoms, it should not be assumed that the patient underwent a screening colonoscopy. According to the US Preventive Services Task Force, “Individuals with a personal history of cancer or adenomatous polyps are followed by a surveillance regimen, and screening guidelines are not applicable.3 The point is that code assignment must be based on the physician’s documentation regarding the reason for the procedure. If the documentation is not clear or if it contains conflicting information, seek clarification from the provider regarding what procedure was performed.
According to the ICD-9-CM Official Guidelines for Coding and Reporting, “The follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists… Should a condition be found to have recurred on the follow-up visit, then the diagnosis code should be used in place of the follow-up code.”4
Often, a colonoscopy is performed following the removal of sessile polyps to determine and document total excision of the polyp. This form of colonoscopy is not considered a screening colonoscopy but rather a follow up or surveillance colonoscopy. Review official coding guidelines and payer policies for diagnostic colonoscopy performed following a history of previous colon polypectomy. For Medicare patients, evaluate local and national coverage determination policies specific to your facility.
Code assignment must be based on documentation by the physician regarding the reason for the procedure. Follow official coding guidelines regarding screening and surveillance colonoscopy and follow payer policies on coding and billing for colonoscopy. Coding Clinic for ICD-9-CM contains several articles on follow-up colonoscopy and screening colonoscopy. The Medicare Learning Network’s Guide to Medicare Preventive Services provides coding and billing information regarding preventive services such as screening colonoscopy. This guide is a useful reference for coding preventive services performed on Medicare patients.
1. National Center for Health Statistics. ICD-9-CM Official Guidelines for Coding and Reporting (October 1, 2011): 71. Available at http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm.
2. Medicare Learning Network®. Centers for Medicare and Medicaid Services. The Guide to Medicare Preventive Services, Fourth Edition (March 2011): 184. Available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads//mps_guide_web-061305.pdf.
3. US Preventive Services Task Force. Screening for Colorectal Cancer: Clinical Summary of US Preventive Services Task Force Recommendation. AHRQ Publication No. 08-05124-EF-4 (October 2008). Available at http://www.uspreventiveservicestaskforce.org/uspstf08/colocancer/colosum.htm.
4. National Center for Health Statistics. ICD-9-CM Official Guidelines for Coding and Reporting (October 1, 2011): 75. Available at http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm.
A.D.A.M. Medical Encyclopedia [Internet]. Atlanta (GA): A.D.A.M., Inc.; ©2012. Colon Cancer Screening (Updated November 8, 2010). Available at http://www.nlm.nih.gov/medlineplus/ency/article/002071.htm.
American Hospital Association. “Discontinuation of Coumadin Therapy Prior to Colonoscopy.” Coding Clinic® for ICD-9-CM Third Quarter 2002: 14-15.
American Hospital Association. “Follow-up Exam Post Colon Polypectomy, No Recurrence.” Coding Clinic® for ICD-9-CM Third Quarter 1992: 11. (Note: the codes have changed but the advice remains consistent with current guidelines).
American Hospital Association. “Screening 10/1/2001.” Coding Clinic® for ICD-9-CM. Fourth Quarter 2001: 55-56.
Centers for Medicare and Medicaid Services. Medicare Coverage Database (Search for diagnostic colonoscopy performed April 5, 2012). Available at http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx.
Judy Bielby is a clinical assistant professor at the University of Kansas and a consultant with Durst & Associates in the Kansas City, MO, area.