Wiki GI coding


Greensboro, NC
Best answers
I work for a GI practice whose physicians also perform procedures at the hospital.
Pt seen in hospital for a Colonoscopy. Pt presents with symptoms - abdominal pain and anemia. Findings from colonoscopy state - diverticulosis.

How should the physician service be coded - should symptoms be sequenced first with findings as secondary or should findings only be submitted with no symptoms added.

Thanks in advance.
I always use the finding. 562.10

per ICD-9 Guidelines found at the beginning of the book:

Section IV: Diagnostic Coding and Reporting Guidelines for Outpatient Services

"For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses."

If you ever have the path report, I use the findings from it as the primary dx.

ex from where a polyp was removed and sent to path and lab, at the time of coding, and path states cancer, I would use the cancer dx as primary.