A: Although the indication for the colonoscopy was for screening purposes, the indication for CT colonography is for a known obstructing lesion and, therefore, should be coded as a diagnostic CT colonography study. As of July 1, 2004, the code used to describe a diagnostic CTC is 0067T.
If the indication for CT colonography were for screening purposes, the screening CTC code (0066T) should be reported even if a positive finding may be found on CTC. The positive finding may be reported as a secondary diagnosis.
Section IV, Diagnostic Coding and Reporting Guidelines for Outpatient Services, of the ICD-9-CM Official Guidelines for Coding & Reporting (http://www.cdc.gov/nchs), as provided by the Centers for Medicare and Medicaid Services and National Center for Health Statistics (developed and approved by the American Hospital Association, the American Health Information Management Association, CMS and NCHS), has been clarified in Program Memorandum AB-01-144 (E),
When a diagnostic test is ordered in the absence of signs/symptoms or other evidence of illness or injury, the physician interpreting the diagnostic test should report the reason for the test (e.g., screening) as the primary ICD-9-CM diagnosis code. The results of the test, if reported, may be recorded as additional diagnoses.