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Gastroenterology Coding Alert

READER QUESTIONS:

What to Do When Doctor Says 1 Thing,Notes Say Another

Published on Sat Apr 04, 2009

Question: How would you code this office visit? Another office refers a 49-year-old patient to our office for an EGD. The patient complains of chronic heartburn,cough, and cramps. After an exam, our physician decides to perform a colonoscopy in addition to the EGD. The EGD confirms the patient has gastroesophageal reflux. The gastroenterologist writes "crampy, lower right abdominal pain" in the indications, but says later she also performed the colonoscopy for screening because the patient was getting close to 50 and colon cancer could be causing the symptoms; had the patient been younger, the doctor would not have performed the colonoscopy because the likelihood of colon cancer would be lower. The patient has no history of colorectal cancer. Maryland Subscriber Answer: For the EGD, you'll code 43235 (Upper gastrointestinal endoscopy including esophagus, stomach,and either the duodenum and/or jejunum as appropriate;diagnostic, with or without collection of specimen[s] by brushing or washing [...]
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