Colonoscopy coding - When coding for the physician

ahansen

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When coding for the physician preforming the colonoscopy, is it ok to just code the colonoscopy from only the op note and not look back at the H & P or Pre op notes? I have heard some other coders are doing this. The reason I ask is that a Dr. may mention symptoms (rectal bleeding possible from hemorrhoids, occasional diarrhea, etc. ) in the prior visit or pre op notes, but then when it comes time to dictate the op note for the colonoscopy he will only list "Screening Colonoscopy" as the pre-op diagnosis. So in this case can I go ahead and use the Z12.11(Screening) as my primary dx. or must I always go by prior visit notes to see if there were symptoms? Is there any guidelines that mentions this? Any help is appreciated!
 

ltrue

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Goddard, KS
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Co-Morbidities

I have always been taught when coding a procedure you only use the diagnoses that pertain to the procedure. Any co-morbidities only get coded for office visits.
 
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