Find information on screening colonoscopy CPT codes, ICD-10 codes, and documentation requirements for accurate medical coding and billing. Learn about Z12.11, the appropriate diagnosis code for a screening colonoscopy, and ensure proper clinical documentation for colon cancer screening. This resource helps healthcare professionals understand the importance of accurate coding for preventative colonoscopies and provides guidance on documentation best practices for a screening colonoscopy procedure. Explore details on polyp removal during screening colonoscopy and related coding guidelines.
Also known as
Encounter for screening colonoscopy
Routine colonoscopy to detect precancerous or cancerous growths.
Enc for screening colorectal ca
General screening for colorectal cancer, including colonoscopy.
Other fecal occult blood present
Positive fecal occult blood test, often leading to colonoscopy.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is there a personal history of colorectal cancer or adenomatous polyps?
Yes
Is surveillance recommended?
No
Is there a family history of colorectal cancer?
When to use each related code
| Description |
|---|
| Screening Colonoscopy |
| Diagnostic Colonoscopy |
| Surveillance Colonoscopy |
Q: What are the most effective strategies for improving adenoma detection rate (ADR) during screening colonoscopy in average-risk patients?
A: Improving adenoma detection rate (ADR) is crucial for effective colorectal cancer prevention. Strategies for maximizing ADR in average-risk patients include optimized bowel preparation with split-dose regimens, careful withdrawal technique with adequate time spent examining the mucosa (at least 6 minutes), and paying close attention to the right colon, where adenomas are frequently located. Furthermore, employing high-definition colonoscopy and considering technologies such as wide-angle colonoscopy or chromoendoscopy can enhance visualization and detection. Consistent implementation of quality assurance measures and ongoing training for endoscopists are also key factors. Explore how implementing a standardized colonoscopy protocol can further improve ADR and patient outcomes.
Q: How can I differentiate between hyperplastic and adenomatous polyps during screening colonoscopy, and when is biopsy or polypectomy indicated?
A: Differentiating between hyperplastic and adenomatous polyps during colonoscopy can be challenging. While visual inspection with high-definition white light colonoscopy can provide some clues based on morphology (sessile, pedunculated, surface texture), definitive diagnosis relies on histopathological evaluation. Biopsy is generally recommended for all polyps detected during screening colonoscopy. Polypectomy is indicated for all adenomatous polyps regardless of size due to their neoplastic potential, as well as for any polyp that is difficult to characterize visually or larger than 5mm. Hyperplastic polyps in the rectum and sigmoid colon generally do not require removal unless they are large, numerous, or have atypical features. Consider implementing advanced imaging modalities like narrow band imaging (NBI) to improve real-time characterization of polyps during the procedure. Learn more about the latest guidelines for polyp surveillance after polypectomy.
Screening colonoscopy performed on (Date) on a (Age)-year-old (Gender) patient with a medical history of (Pertinent medical history, e.g., hypertension, hyperlipidemia, family history of colon cancer) presenting for colorectal cancer screening. The patient reported (Symptoms if any, e.g., no abdominal pain, no change in bowel habits, or positive for constipation, blood in stool). Prior to the procedure, the patient underwent bowel preparation with (Bowel preparation method, e.g., polyethylene glycol solution) and tolerated it (Well or poorly). During the procedure, the patient was monitored with (Monitoring method, e.g., continuous pulse oximetry and electrocardiography). The colonoscope was advanced to the (Location reached, e.g., cecum) without difficulty. The examination revealed (Findings, e.g., normal colonic mucosa, diverticulosis in the sigmoid colon, polyp(s) in the (Location), etc.). (If polyps were found: Number) polyp(s) measuring (Size) were removed via (Removal method, e.g., cold forceps polypectomy, snare polypectomy, or hot snare polypectomy) and sent for pathological examination. There was no evidence of (Findings ruled out, e.g., strictures, masses, inflammation, or bleeding). The patient tolerated the procedure well and was discharged in stable condition. Post-procedure instructions were provided including (Specific instructions, e.g., diet recommendations, follow-up colonoscopy recommendations based on findings). ICD-10 code (Appropriate ICD-10 code, e.g., Z12.11 for encounter for screening for malignant neoplasm of colon) and CPT code (Appropriate CPT code, e.g., 45378 for colonoscopy, flexible; diagnostic, including collection of specimen by brushing or washing, when performed) were used for billing. Follow-up recommendations include (Specific follow-up, e.g., pathology review, repeat colonoscopy in (Number) years).