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!
-
If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
Wiki Colonoscopy coding - When coding for the physician
- Thread starter ahansen
- Start date
mitchellde
True Blue
You cannot use notes from a previous encounter, you code based on the note you have.
ltrue
Contributor
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.
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.