colonoscopy

A patient books an office visit appointment with our surgeon and the reason the patient is coming in is he/she is planning on having a screening colonoscopy. During the exam the doctor does an occult stool test and it is positive for heme positive stool. The question is since the patient made the appointment to have a screening colonoscopy, when the procedure is performed, is this still considered a screening, or is this now considered diagnostic because heme positive stool was found at the time of visit?

Thank you.

re: colonoscopy

It depends on what procedure that the doctor ends up performing but I would still bill the screening DX along with any other DXs.

re: colonoscopy

I understand that if he removes polyps or does a biopsy that we would then use the appropriate code(s) for what was done, and since it started out with the intent of a screening, we would then use modifier 33 or PT as appropriate. I just wanted to be sure that since the intent of the office visit and procedure was for a screening colonoscopy and the heme positive was only found at the time of that office visit, that going into the procedure is still actually considered a screening. If it turns out to be a normal colonoscopy and no biopsies were taken and no polyps removed, it would be billed as a screening.

Thank you.

re: colonoscopy

I would consider it an incidental finding if it is documented that the intent of the office visit and procedure is/was for a screening colonoscopy.