We have a patient who had a colonoscopy in August 2014, and one sigmoid polyp was removed. In the operation note, it was originally put in the plan to repeat the colonoscopy in five years; however, when the pathology report came back, the polyp was hyperplastic, and the doctor changed the recall status to 10 years. The patient is scheduled for a recall colonoscopy in August 2024. Is this patient eligible for an ICD-10 code Z12.11 screening procedure? Or would this be coded with ICD-10 code Z86.010, personal history of colonic polyps, as the primary indication?
ASGE Answers Your Coding Questions
ASGE members may submit coding inquiries electronically to codingquestions@asge.org. When submitting a question, please allow at least three business days for a response. When submitting inquiries, please include the ASGE member’s name and ID number. Only questions will be accepted and not reports. Below are two questions that could be beneficial to your practice.
Question #1
We have a patient who had a colonoscopy in August 2014, and one sigmoid polyp was removed. In the operation note, it was originally put in the plan to repeat the colonoscopy in five years; however, when the pathology report came back, the polyp was hyperplastic, and the doctor changed the recall status to 10 years. The patient is scheduled for a recall colonoscopy in August 2024. Is this patient eligible for an ICD-10 code Z12.11 screening procedure? Or would this be coded with ICD-10 code Z86.010, personal history of colonic polyps, as the primary indication?
Answer
This would be a screening, Z12.11. The code Z86.010 is only used when there is a personal history of benign neoplasm(s) of the colon, i.e., adenomas, sessile serrated polyps.
Question #2
We have a patient in the hospital who was seen only by the resident, but our GI doctor signed the note. There is no addendum or attestation stating that our doctor saw the patient. Is that visit billable by us since our doctor did sign off on the note and the resident is a hospital physician?
Answer
The teaching physician must document that he or she personally saw the patient, personally performed critical or key portions of the service and participated in the management of the patient. The teaching physician's note should reference the resident's note.