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Bleeding Hemorrhoids

  1. #1
    Default Bleeding Hemorrhoids
    Medical Coding Books
    Patient came in for colonoscopy with pre-op DX of rectal bleeding. Post-operatively, the doctor's DX was Internal Hemorrhoids, likely source of recent rectal bleeding.

    Does the word likely preclude using 455.2 as a DX? ICD-9 guidelines includes "likely" as a qualified DX and not to be coded in an out-patient setting. Does the doctor need to definetively state that hemorrhoids are the source of the bleed?


  2. #2
    East Stroudsburg, PA
    In my experience for profession coding the doctor needs to make the direct link from the rectal bleeding to the hemorroids. If he is still pending tests such as biopsy or a stool test this might be the reason for the use of "likely" and this would not have an impact on coding for the professional.

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