Ulcerative colitis in remission


Archdale, NC
Best answers
If a patient with a history of UC has a surveillance colonoscopy and all bx come back negative, the Dr's comment is UC "in remission" what is the correct Dx code?
My inclination would to be use a follow-up code - Z09 along with a personal history code - Z87.19. Not sure how payers are going to respond to that, but I would appeal any denials.

You might also consider it to be the same episode of care, depending on when it was last active. IIRC, the best example of the same episode of care was a child with otitis media who returns for a follow up to make sure it resolved. The guidance stated you should still use otitis media as the diagnosis because it was the same episode of care, even though technically it was not active. This would require a judgment call on your part because if it hasn't been active for years, I don't think you could realistically deem it to be the same episode of care.