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General Surgery Coding Alert

You Be the Coder:

Surgeon May Have Final Say in Dx Coding

Published on Fri Jun 17, 2022

Question: The surgeon submitted an esophageal biopsy taken during an esophagogastroduodenoscopy (EGD) with no mention of esophageal bleeding for a patient diagnosed with GERD. The pathology report noted “inflammation and reactive changes to the squamous mucosa.” What are the procedure and diagnosis codes for this case? Georgia Subscriber Answer: You should code from the pathology report when the findings provide a definitive [...]
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