When coding for Pre-visit and colonoscopy is a struggle. The surgeons I work for will sometimes state in the note recent history of symptoms and now the symptoms have resolved. Would those symptoms at the time of referral to the surgeon, pre-visit, or procedure determine whether the patient is symptomatic versus asymptomatic.

For example, I have a patient that was seen in the office that was referred with abdominal pain and blood in stool. The provider states that those symptoms have resolved. Would the recent symptoms be considered or is the patient now considered asymptomatic?

Also, on the visit will state screening colonoscopy but state patient has diarrhea or constipation. Then the Op note will only state that the indication is for screening. Is the office visit have any determining factor when your aware there is a contradiction?

Also, I’ve read when coding surveillance colonoscopies to code first Z08 or Z09 depending on the history diagnosis. Is that a recommended practice? I’ve always used my history code(reason for surveillance) as my primary code. Is this something that changed with ICD-10.

Thank you in advance for your time.

Melissa Stogsdill, CPC, CGSC