Coding Surveillance Colonoscopy

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.


  1. The question I have is the surgeon is seeing the patient in office for screening for colon cancer, but the patient is only in the office to set up a surgery appointment for the screening the procedure is not being performed. There is no other diagnosis other than it is time for screening. Should we use the screening code for this visit even though the procedure has not been performed yet?

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  2. Many commercial payers do not look at colonoscopies that are f/u to a previous colonoscopy and being performed more frequently then the 10 year screening intervals, most commonly due to history of polyps, as a screening service. They look it as surveillance. If the Z12.11 for screening is put on the claim they will process it as screening but later review results in take-backs. My understanding is that Z86.010 and Z12.11 should not be coded together. I am trying to find the literature that thought came from. Can you clarify this ?

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    • Please see this

      will this help for you?

      ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2017 Page: 9

      A patient, who is status post removal of adenomatous colon polyps five years ago, presents to the GI lab for surveillance colonoscopy. The colonoscopy is completely normal and the provider recommends surveillance colonoscopy in ten years. What is the correct diagnosis code assignment?
      Assign code Z12.11, Encounter for screening for malignant neoplasm of colon, as the first-listed diagnosis for the surveillance colonoscopy. Code Z86.010, Personal history of colonic polyps, should be assigned as an additional diagnosis. A surveillance colonoscopy is still a screening, and patients are being screened for malignancy; however, it is considered a high-risk screening exam due to the history of previous polyps.

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  3. Hi All, let me explain this scenario, pt had previous colonoscopy on 2017 and now (06/14/2018) he came for surveillance colonoscopy with polyp removed and proved as benign neoplasm of colon(D12.3), no signs and symptoms at the time of visit, indication of OP Report, chief complain of HPI all states as surveillance colonoscopy, as per medicare MLN Matters: For beneficiaries considered to be at high risk for developing colorectal cancer, Medicare covers one screening colonoscopy every two years, regardless of age, so for this scenario what dx needs to be primary dx? since patient visited with in year! is that Z09 or Z12.11 or D12.3, I did not find any CPT assistant or Coding Clinic to support my scenario, looking forward your inferences, thanks in advance.

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  4. Providers are contracted with payers who have polices stating a surveillance colonoscopy is not considered a screening colonoscopy and will not apply the screening benefits for a patient with a history of colon polyps. How then can we apply the guidance in the AHA Coding Clinic which directly contradicts the payer policies in which we are contracted?

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  5. Does CMS limit the number of surveillance (Z86.010) office visits a member can have in given time period. Sometimes we see pts that are not having any issues before their surveillance colo and have been billing the preop code of Z01.818 but now I think I’ve been leaving money on the table by doing this. Can I bill a Z86.010 on all of them or is there a time limit?

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  6. We routinely see patients for outpatient screening colonoscopies. The doctor finds hemorrhoids and does a banding. He codes as follows: 45398 (sometimes with PT, 33 or modifier) with ICD-10: z12.11 & k64.1. Nine out of ten times it gets applied to deductible or we get a denial saying diagnosis is inconsistent with the procedure. What are we doing wrong?

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  7. I have a scenerio where the surgeon is doing a “follow-up colonoscopy” for h/o diverticulitis. Only diverticulosis was found. The pre-op visit states the patient is currently asymptomatic. The patient has had recurrent diverticulitis. Would this be coded with Z87.19 or Z09 with K57.32?

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  8. My question comes from the lab, our pathologist received 7 biopsies on a patient who had a screening colonoscopy, that has a personal history of colon polyps, personal history of crohns, family history of colon cancer…..lab billed claim with K52.9 code for billing, should they be using any screening codes?

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