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Gastroenterology Coding Alert

READER QUESTIONS:

Use Physician Notes to Narrow Crohn's Choice

Published on Sun Jan 10, 2010

Question: A new Medicare patient reports to the gastroenterologist with complaints of diarrhea, stomach pain, and loss of appetite for the past week. The gastroenterologist performs a level-three E/M; suspecting Crohn's disease, she performs a colonoscopy with biopsy. Test results come back positive for Crohn's, but negative for cancer. How should I code this scenario? Iowa Subscriber Answer: You'll need to double check the notes to see if the physician specified the type of Crohn's disease. Further, it is unusual to have a new patient visit on the same day as a colonoscopy because the procedure requires the patient to complete a full colonoscopy preparation. If the notes indicate that the patient was fully prepared for the colonoscopy on the day of the initial visit, report the following codes: • 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) for the colonoscopy • 99203 (Office or other [...]
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