Question

Dr. Caddell performed a colonoscopy at the ambulatory surgery center on Cecil Matthews, who has been Dr. Caddell's patient for several years. Mr. Matthews came to the office with left lower quadrant pain and a history of colon cancer. What other factors or information would Sherald need to know to properly code Mr. Matthews' office visit? What medical documentation would Sherald need to properly code Mr. Matthews' office colonoscopy?

Answer 1

Sherald needs to know whether Mr. Mathew is a new patient or an old existing patient. She needs to confirm whether the colonoscopy is done as a screening procedure or diagnostic procedure. Screening of colonoscopy is done when there is no signs and symptoms and the diagnostic procedure is done to detect the abnormalities. The coder needs to know the findings of the colonoscopy. The coder also needs to know the patient's present problem and history associated with colonoscopy and reason for physician advice for colonoscopy. Sherald should mention proper modifier if any polyps were removed during the procedure. The medical document of the lab report, investigation associated with colonoscopy, report of the new existing problem all should be evaluated before properly coding of colonoscopy.