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Dx Question

  1. Default Dx Question
    Medical Coding Books
    Just a quick question, I code for an ASC, in the ICD-9 guidelines it says to report the post op dx if it is different from the pre-op dx, because the post-op dx is more definitive. But as an example, what if a Doctor performs a colonoscopy, his pre-op dx is abdominal pain, his post of dx is internal hemorrhoids. Internal hemorrhoids is not on the carriers LCD list for a colonscopy can you report both diagnosis, the pre-op and the post-op ???
    Thanks in advance for any responses.

  2. #2
    I'm curious to find out a more concrete response to this as welll especially when the finding is hemorrhoids.

  3. #3
    Columbia, MO
    Does the provider indicate the hemorrhoids are the reason for the abd pain? If he just mentions the hemorrhoids are present but not explain the patient presenting symptoms then yes you code the symptom first and the finding secondary. If the finding is documented as the reason for the symptom then no you do not code code both.

    Debra A. Mitchell, MSPH, CPC-H

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