AHA Coding Clinic® for ICD-9 - 2013 Issue 4; Ask the Editor
Screening, Surveillance, and Follow-up Colonoscopies
A 55-year-old male underwent a screening colonoscopy and a large polyp was found. Due to its size, and the inability of the gastroenterologist to visualize the base of the polyp, it was only partially removed. The pathology confirmed tubulovillous adenoma and the provider recommended a follow-up colonoscopy in three months. How would this encounter be coded? ...
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Article Overview
This article covers colonoscopy encounters that begin as screening exams and later involve findings that lead to surveillance or follow-up. It is aimed at coders, billing staff, and clinical documentation teams who need to understand how screening status, subsequent findings, and later colonoscopy planning are discussed in coding guidance. The article presents general guidance in the context of colonoscopy encounters and related diagnosis classification.
Why This Topic Matters
Screening colonoscopy encounters can remain classified as screening even when additional findings are documented, and that distinction affects how the record is interpreted for coding and reporting purposes.
What You Will Learn
- How colonoscopy encounters that start as screening exams are discussed in coding guidance.
- How later findings and recommended follow-up relate to the original screening context.
- How documentation is framed when a screening procedure leads to additional clinical assessment.
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Who Should Read This
- Medical coders
- Billing specialists
- Health information management staff
- Clinical documentation specialists
Codes Discussed
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