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Wiki Microscopic colitis

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kirstenoviedo@yahoo.com

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Hello, I have a doctor that billed CPT code 45380 (colon with biopsy) with dx code Z86.010 (personal history of colonic polyps) but then noted on the op repost that he did a biopsy due to " evaluation of microscopic colitis". Do I add R19.7 (Diarrhea) or K52.839 (Microscopic colitis, unspecified)? If anyone could help, I would greatly appreciate. Thank you.
 
Good question.
You can't code microscopic colitis as a dx for this patient unless you see it on the path report, or if the doctor states the patient has been diagnosed with microscopic colitis. I don't get that from reading what you said about the op report. The "due to evaluation of microscopic colitis", that's a little bit confusing. It could mean they want to evaluate for microscopic colitis. The way it reads now, I wouldn't code microscopic colitis from this sentence assuming it is being done for evaluation purposes. You don't have that definitive diagnosis yet.
I read something like this frequently in op reports and it usually reads "to evaluate FOR microscopic colitis". And since that is a rule - out scenario, I code the symptoms that are given. If diarrhea is given , then I would just code the diarrhea. Or whatever signs/symptoms/indications you have on the op note. History of polyps and diarrhea, for example, if that is what is on your op note.
IF you have a pathology report and IT states microscopic colitis, then you can code that.
Hope this helps.
 
nsteinhauser said:
Good question.
You can't code microscopic colitis as a dx for this patient unless you see it on the path report, or if the doctor states the patient has been diagnosed with microscopic colitis. I don't get that from reading what you said about the op report. The "due to evaluation of microscopic colitis", that's a little bit confusing. It could mean they want to evaluate for microscopic colitis. The way it reads now, I wouldn't code microscopic colitis from this sentence assuming it is being done for evaluation purposes. You don't have that definitive diagnosis yet.
I read something like this frequently in op reports and it usually reads "to evaluate FOR microscopic colitis". And since that is a rule - out scenario, I code the symptoms that are given. If diarrhea is given , then I would just code the diarrhea. Or whatever signs/symptoms/indications you have on the op note. History of polyps and diarrhea, for example, if that is what is on your op note.
IF you have a pathology report and IT states microscopic colitis, then you can code that.
Hope this helps.
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Thank you !!!
 
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