Wiki First listed diagnosis for surgical evaluation for colon polyp

adinson

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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 :D
 
Generally speaking, conditions that are evaluated or treated at a given encounter should be coded as active conditions until such time as the provider determines that the condition is resolved, after which they will become history, for coding purposes, at any subsequent encounters, not at the current encounter. If the documentation shows that this condition was not determined to have been resolved prior to the encounter, then I would code this as an active condition, since that code best reflects the reason for the visit and the condition which the physician is evaluating. If you code an encounter with the history code, then you are effectively stating that the patient is been seen because they have a past history of a given condition, not because they require an evaluation of a condition that exists or existed at the time of the encounter.

In the example you give here, I would agree with the physician's diagnosis of a neoplasm. That was a diagnosis confirmed by pathology that was not determined to have been resolved at the time the patient saw the physician. I don't believe the GI doctor would have referred this patient to a surgeon if the determination had already been made that the condition was no longer present or was not in need of evaluation or treatment.
 
T
Generally speaking, conditions that are evaluated or treated at a given encounter should be coded as active conditions until such time as the provider determines that the condition is resolved, after which they will become history, for coding purposes, at any subsequent encounters, not at the current encounter. If the documentation shows that this condition was not determined to have been resolved prior to the encounter, then I would code this as an active condition, since that code best reflects the reason for the visit and the condition which the physician is evaluating. If you code an encounter with the history code, then you are effectively stating that the patient is been seen because they have a past history of a given condition, not because they require an evaluation of a condition that exists or existed at the time of the encounter.

In the example you give here, I would agree with the physician's diagnosis of a neoplasm. That was a diagnosis confirmed by pathology that was not determined to have been resolved at the time the patient saw the physician. I don't believe the GI doctor would have referred this patient to a surgeon if the determination had already been made that the condition was no longer present or was not in need of evaluation or treatment.
That makes such perfect sense, thank you! I will be printing your response for my notebook. I was searching the internet for 2 hours and could not find an answer as clear as yours, happy holidays!
 
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