A patient and clinic want me to change the diagnosis code to a screening code as primary. I've stated how I am unable to do so with the information I have. I would like to share and see if you all would validate me. This is the path report:
I can include the gross and micro if needed. No stains were done.
I coded this 88305, K29.50
Here's what I think might have happened. The patient might have had an upper endoscopy and a colonoscopy done at the same time. The clinic may have includes the clinical information for both procedures. But my point is that because "dysphagia" is mentioned, I cannot consider that the gastric specimen was from a screening procedure - that the inclusion of "dysphagia" requires that I code this as a diagnostic procedure.
I have requested a copy of the requisition, H&P, and op note to clarify.
I would appreciate your thoughts and expertise! Thanks.
Clinical Information: Screening, dysphagia, diverticulosis
Final Diagnosis: Gastric antral mucosa with no significant pathologic findings. Minimal Chronic inflammation is present. Negative for H. Pylori organisms.
Specimen: Biopsy of gastric antrum, erythema
Final Diagnosis: Gastric antral mucosa with no significant pathologic findings. Minimal Chronic inflammation is present. Negative for H. Pylori organisms.
Specimen: Biopsy of gastric antrum, erythema
I can include the gross and micro if needed. No stains were done.
I coded this 88305, K29.50
Here's what I think might have happened. The patient might have had an upper endoscopy and a colonoscopy done at the same time. The clinic may have includes the clinical information for both procedures. But my point is that because "dysphagia" is mentioned, I cannot consider that the gastric specimen was from a screening procedure - that the inclusion of "dysphagia" requires that I code this as a diagnostic procedure.
I have requested a copy of the requisition, H&P, and op note to clarify.
I would appreciate your thoughts and expertise! Thanks.