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Screening Colonoscopy after positive Cologuard

Tammy Posted Mon 17th of September, 2018 07:58:16 AM
A patient has been referred for screening colonoscopy after a positive Cologuard. What would be the proper diagnosis? Z12.11, or R19.5? By using R19.5 (occult blood in feces) as the indication, will the patient still receive screening benefits or will it become diagnostic? It seems to me that if a patient were to loose screening benefits because of using the Cologuard test it would deter ever using it. Would a 33 modifier be appropriate in this case? Please advise.
SuperCoder Answered Tue 18th of September, 2018 05:28:33 AM

Screening Colonoscopy versus Diagnostic Colonoscopy:

Screening colonoscopies ordered in the absence of signs or symptoms of disease to identify colorectal cancer (CRC) or polyps. Mostly insurers define who is eligible for a covered screening based on risk groups.

Medicare typically covers screening colonoscopies once every 10 years beginning at age 50 for asymptomatic beneficiaries at "normal risk" of developing CRC.

Medicare covers screening colonoscopy once every two years, regardless of age, for "high risk" patients demonstrating one of the following situations:

  • A close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp
  • A family history of familial adenomatous polyposis (FAP)
  • A family history of hereditary nonpolyposis colorectal cancer
  • A personal history of adenomatous polyps
  • A personal history of colorectal cancer
  • Inflammatory bowel disease, including Crohn's Disease, and ulcerative colitis.

Whereas, in diagnostic colonoscopy, the provider performs a diagnostic procedure when a patient presents with symptoms that require investigation. This might include issues like chronic diarrhea, significant hematochezia, or a questionable abnormality noted on an imaging study. Assuming that an office note or pre-procedure note details the patient's complaint, the subsequent procedure will be a diagnostic colonoscopy. This is true even if the patient has never had a prior routine screening colonoscopy.

Your patient has been referred for screening colonoscopy after a positive cologuard, means there is already a diagnosis, so it will be considered as diagnostic colonoscopy. As described above, screening is something which is prefixed. ICD Z12.11 only can be used in case of screening procedures. On the other hand, if screening for the patient is prefixed, then it can be done.

Modifier 33 is not appropriate here, append modifier 33 to services which are preventive, such as screenings for specific diseases. Also, do not append modifier 33 to services that are inherently screening services and contain the word screening in the descriptor, such as a screening mammogram.

Hope this helps!

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