Tune in to this monthly online coding column, facilitated by AHIMA’s coding experts, to learn about challenging areas and documentation opportunities for ICD-10-CM/PCS.
By Elena Miller, MPH, RHIA, CCS
I don’t know about anyone else but I was very happy to see Coding Clinic revisit outpatient colonoscopies this year. Some coding professionals have always been very comfortable with outpatient colonoscopy cases, but for others it can be a slippery slope. Outpatient colonoscopies had previously been clarified in the fourth quarter issue of the 2013 ICD-9 Coding Clinic, then came the ICD-10 code set—which created confusion all over again.
In my opinion, the confusion has always seemed to revolve around surveillance colonoscopies and whether the coder should follow the guidelines for screening or follow-up. Most coders use an encoder today; if the word “surveillance” is entered in the encoder it leads the coder down the path to a follow-up code. The coding guidelines state that “the follow-up codes are used to explain continuing surveillance following completed treatment of a disease, condition or injury.” Without looking any further it would seem that a follow-up code would be most appropriate. That is incorrect, however, when it comes to coding a surveillance colonoscopy, specifically. The Bulletin of the American College of Surgeons describes a surveillance colonoscopy as a subset of screening. In addition, the second quarter 2017 issue of Coding Clinic confirmed previous guidance stating that a surveillance colonoscopy is a screening exam and therefore it must be coded utilizing screening guidelines.
Now that coding professionals are all on the same page regarding code assignment, problem solved… right? If only it were that simple; just like many other issues the problem is compounded by physician documentation. Some physicians use screening, follow-up, and surveillance interchangeably in the medical record documentation without regard for presenting symptoms. Coders cannot take this information at face value. A thorough review of the documentation must be performed, including review of the history and physical submitted from the office. Often, the procedure note will only state the indication for test as “surveillance” but the history and physical will give more information as to why the exam was ordered. Coding guidelines for screening exams state that “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.” The key point in that statement is when a patient has a sign or symptom prompting the exam, it is not a screening exam. Surveillance colonoscopies are ordered because the patient had a previous finding of cancer or polyps, but are currently asymptomatic. Coders need to pay special attention to the documentation to determine whether the patient is asymptomatic or not.
It can be very difficult for a coder to see a surveillance or screening exam documented by a physician but make the determination that the exam does not meet the definition of screening based on documentation of active symptoms such as rectal bleeding, abdominal pain, anemia, or diarrhea. Coders should work with their coding leadership to determine the best approach to handle situations in which the medical record documentation doesn’t support the type of exam documented.
Elena Miller is the director of coding audit and education at a healthcare system.