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Paul Cadorette, CPC, CPC-H, CPC-P, CEDC, COSC, CASCC, is director of education for mdStrategies.
Q: If the doctor states in the op note under indications for colonscopy as screening for colorectal cancer and rectal bleeding, then would I not code it as a screening even though the doc is stating it as one of the reasons for the colonscopy?
Paul Cadorette: When presenting for a screening procedure, the patient should be asymptomatic (without signs or symptoms). Since the patient presents with rectal bleeding, the purpose of the procedure is to diagnosis the source of the bleeding, so the procedure does not qualify as a screening and V76.51 would not be reported.
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Read more insight from Paul Cadorette:
- Coding Guidance: Adjacent Tissue Transfers
- Polyp Ablation Using Snare Tip