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Reporting non-alarming symptoms

Hayley_Sutton

Contributor
Messages
14
Location
Graham, NC
Physician saw the patient for their screening consultation. Patient complained of constipation, but stated it was due to her new low carb diet. In the office note, the physician states the constipation is not an alarming symptom and therefore, recommends a screening colonoscopy.

Because the constipation was mentioned in the HPI, Review of Systems, and it was mentioned as a non-alarming symptom in the impressions, should constipation be reported on a claim?

I am billing for the visit as patient is also having an EGD for dysphagia. My dilemma is: I am thinking if I report this code on the claim this will override the screening code even if it is not listed first. But, even though the physician is not treating it, it still needs to be reported just like I would if the patient has COPD or something else.

Help!!
 
I would not report it. The patient mentioned in the ROS and the provider dismissed it. Patients will often bring up things just to be full disclosing to the provider. In this case the provider immediately accepted the patient explanation and has dismissed this as worthy of note or concern.
 
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