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Thread: dx re: reason for procedure vs findings

  1. #1
    Join Date
    Apr 2007
    Kansas City

    Default dx re: reason for procedure vs findings

    AAPC: Back to School
    if a patient had a colonoscopy for constipation and blood in stool, however, the provider found a colon polyp and uncomplicated internal hemorrohoids - would you code all diagnoses or just the findings?

    you can e-mail me directly at: coding_compliance@msn.com
    Shellie Sulzberger, LPN, CPC
    Coding & Compliance Initiatives, Inc.

    website: www.ccipro.net

  2. #2
    Join Date
    Apr 2007
    Portland, Oregon

    Wink procedure vs findings

    Hi Shellie,

    You should use the most specific diagnosis appropriate for the patient and make sure it is well-documented in the medical record.
    Also, you should check on EdgeBlast #120 March 2009, title: CT Colonography Fails NCA test. That would be help.

    I hope it can help,

    Good luck,

  3. #3
    Join Date
    Apr 2007
    Charlotte, NC


    I would put the colon polyp on line one and the constipation and blood in stool on subsequent lines as additional dx if needed.

  4. #4


    I would bill colon polyp as primary diagnosis (make sure you go by path results), bleeding as second, and constipation as third. The colon polyp is reason for polypectomy.

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