Wiki dx re: reason for procedure vs findings

[ShellieSulzberger]

if a patient had a colonoscopy for constipation and blood in stool, however, the provider found a colon polyp and uncomplicated internal hemorrohoids - would you code all diagnoses or just the findings?

you can e-mail me directly at: coding_compliance@msn.com

 

[thythaot]

procedure vs findings

Hi Shellie,

You should use the most specific diagnosis appropriate for the patient and make sure it is well-documented in the medical record.
Also, you should check on EdgeBlast #120 March 2009, title: CT Colonography Fails NCA test. That would be help.

I hope it can help,

Good luck,

 

[coachlang3]

I would put the colon polyp on line one and the constipation and blood in stool on subsequent lines as additional dx if needed.

 

[acbarnes]

I would bill colon polyp as primary diagnosis (make sure you go by path results), bleeding as second, and constipation as third. The colon polyp is reason for polypectomy.