dx code??

j-fowler57

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Just curious.... what dx. do you use when the dr. documents for a colonoscopy "change in bowel habits, abdominal pain, blood in stool, hx of polyps, colon cancer screening"???? And the results are no findings. Doesn't matter if they are private or medicare pay.

I thought symptoms over ruled screening??

:confused:
 

lmartien

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Screening vs. symptoms

I would default to the reason the patient is presenting for the procedure. Is it for a screening (then would use that dx) or is it because the patient is experiencing symptoms? (then would use the symptom dxs, symptoms before history of)
 

j-fowler57

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But how do I know which to default to when he uses symptoms and a screening?? I know not to use the hx of as px but when he is using everything else I'm not sure which to use... symptoms or screening??????????
 

coachlang3

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In this case you should use the symptoms as that is what the doctor dictated. However, what I think lmartien was meaning is to go to the OV note and find out the reason the pt came in in the first place.

Did they come in under the impression they were coming for a screening and then they opened their mouth under questioning or did they present to your doctor with symptoms. Look back to the previous OV note if possible. Otherwise you will either need to contact the doctor for clarification and to let them know they need to put an addendum on the note or you just code from th OP note (which is what you should be doing, technically) and code it as diagnostic due to the symptoms.
 

j-fowler57

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I don't have access to OV notes as I work in a hospital setting and read the H/P dictated and I do code from the OR dictation ( and he states it on both )

Thanks for all the input on this. :)I won't go into detail as to why I was asking but this supports my coding. Need to do a little educating I think to this dr. :p:D
 

coachlang3

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In that case I would not code it as a screening. Work with what you have. And I wholeheartedly agree with your statement of physician education.

I also apologize if my statement seems like I was "accusing" you of not coding from the note, I added that as the "general reminder" for all. Didn't mean to imply you weren't. :eek:
 
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