General Surgery Coding Alert

Question:

Michigan Subscriber

The diagnosis code(s) you assign for an encounter should always reflect the information in the note. If the note says the patient is being followed for morbid obesity (278.01, Morbid obesity) that is the diagnosis code you should use, no matter who suggests otherwise.

That said, depending on the documentation for the actual reason your surgeon is seeing the patient, you might use a different diagnosis code. For instance, the physician may be addressing some kind of nutritional deficiency post lap-band, and you should report the appropriate diagnosis code, such as 269.9 (Unspecified nutritional deficiency).

You should also contact your major payers to see what they have to say about follow up visits outside the global period for lap band procedures. They may have specific instructions, such as using V53.51 (Fitting and adjustment of gastric lap band) if the encounter is for making adjustments to the lap band.

Caution: You must be very careful about information from sales people. Although they rarely give you absolutely incorrect information, they sometimes don't give you a full picture of how things should be handled or, depending on their knowledge and experience, they may tell you what they believe is true but it may not be fully correct.

Do this: Assign the diagnosis code based on good documentation of the actual reason for the patient encounter, along with a good knowledge of coding alternatives for your various payers.