adinson
Guest
Hello, I'm a new CPC-A and I'm trying to understand how to select diagnoses for office visits. Am I selecting the diagnosis based on the reason for the visit? Or for the patient's condition at the time of the visit? I know it can be the first one if a diagnosis is not established, and the second if the diagnosis IS established. Here is why I ask:
Patient was referred by GI doctor because multiple polyps were removed during colonoscopy and one was biopsied. The path report came back as "tubulovillous adenoma with high grade dysplasia", so that doc referred to our doc (general surgery) for evaluation for colon resection. Upon reviewing the patient's path and procedure report, our doc decided surgery was not supported because the polyps were COMPLETELY removed during the colonoscopy.
Our doc selected the diagnosis as the neoplasm. I selected the diagnosis as the personal Hx of colon polyp, because the polyp was completely removed. So therefore, should I be coding the visit based on the reason for the referral (the neoplasm)? or for the patient's condition at the time of the visit (history of colon polyp)?
Thank you
Patient was referred by GI doctor because multiple polyps were removed during colonoscopy and one was biopsied. The path report came back as "tubulovillous adenoma with high grade dysplasia", so that doc referred to our doc (general surgery) for evaluation for colon resection. Upon reviewing the patient's path and procedure report, our doc decided surgery was not supported because the polyps were COMPLETELY removed during the colonoscopy.
Our doc selected the diagnosis as the neoplasm. I selected the diagnosis as the personal Hx of colon polyp, because the polyp was completely removed. So therefore, should I be coding the visit based on the reason for the referral (the neoplasm)? or for the patient's condition at the time of the visit (history of colon polyp)?
Thank you