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Colonoscopy dx


Tulsa, OK
Best answers
Ok, my department needs some help. Here is an example: Scenerio #1: We did a colonoscopy because the patient had abdominal pain and we found that the patient had diverticulitis--do we code 780.0X or 562.1X? Scenerio #2: We do a screening colonoscopy and find that the patient has diverticulitis, we do no other procedure, do we dx code the screening then the diverticulitis, or just the diverticulitis?

Any help, references would be great!


Best answers
In Scenerio 1 if the abdominal pain is being caused by the diverticulitis 562.11 (which it probably is because diverticulitis usually causes severe stomach pain) I would code for the diveticulitis alone. If you look at the your ICD-9 guidlines at the front of your book page 3 of the coding guidelines. It's technically under Section 1, subheading B. Coding guidlines, number 7 it says " Signs and symptons that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification. If the patient has Diverticulosis...which I have a feeling that's what your talking about (562.10) then it is very common to find that...To my knowledge it is not painful and wouldn't account for the abdominal pain. So in that case I would code 789.00 and the 562.10 second.

Scenario 2 you definitely want to code the V76.51 first and then for what I think you mean as diveticulosis and not diverticulitis. Code the 562.10 as secondary. If you look in your ICD book page 17. It's under the screening subheading (which starts on page 16) The 3rd paragraph down is says "A screening code may be a first listed code if the reason for the visit is specifically the screening exam". In the next paragraph it says "Should a condition be discovered during the screeing then the code for the condition may be assigned as an additional diagnosis"

Hope that helps :)