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C-scopy screening visit; procedure not done

Maarit Posted Fri 01st of June, 2012 17:24:27 PM

How should this visit be billed out to Medicare? The procedure was not performed, hence the visit is not bundled to anything. V76.51 denied the claim. Also, what is the E/M level? 99201, since time spent was not documented and there was no exam. See below:

Patient who is 86 years old patient comes referred for screening colonoscopy. The patient has quite prominent Parkinson's disease and is disabled in that he uses a walker with difficulty to move around. He has constipation because of Parkinson's medications. He uses laxatives and some MiraLax. She has mild rectal prolapse and has been seen recently by Dr. X. At that time they discussed colonoscopy and Dr. X did not feel he needs one. The patient denies any bleed per rectum. He has a normal complete blood count. He has average risk for colon cancer.
Guidelines do not specify colon cancer screening after age of 75. The risk of adverse effects to be at cardiovascular or pulmonary or do to colonoscopy itself do outweigh the benefits at age of about 80. The incidence of colon cancer after age of 80 he is in decline. Therefore screening colonoscopy after age of 80 makes little if any sense. In this regard I believe Dr. X advised is appropriate and valid. I have explained that to the family who agrees.
Should the patient develop any new symptoms such as change in bowel habits, bleeding or symptoms of obstruction consideration of colon exam might be appropriate.

SuperCoder Answered Fri 01st of June, 2012 20:48:06 PM

Its an office visit and no colonoscopy performed and 99201 seems appropriate here with limited components.

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