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GI coding

  1. #1
    Default GI coding
    Medical Coding Books
    I work for a GI practice whose physicians also perform procedures at the hospital.
    Pt seen in hospital for a Colonoscopy. Pt presents with symptoms - abdominal pain and anemia. Findings from colonoscopy state - diverticulosis.

    How should the physician service be coded - should symptoms be sequenced first with findings as secondary or should findings only be submitted with no symptoms added.

    Thanks in advance.

  2. #2
    please see the postings under Gastroenterology. There is a lot of good information regarding dx code sequencing there

  3. Default
    I always use the finding. 562.10

    per ICD-9 Guidelines found at the beginning of the book:

    Section IV: Diagnostic Coding and Reporting Guidelines for Outpatient Services

    "For outpatient encounters for diagnostic tests that have been interpreted by a physician, and the final report is available at the time of coding, code any confirmed or definitive diagnosis(es) documented in the interpretation. Do not code related signs and symptoms as additional diagnoses."

  4. Default

    If you ever have the path report, I use the findings from it as the primary dx.

    ex from where a polyp was removed and sent to path and lab, at the time of coding, and path states cancer, I would use the cancer dx as primary.

  5. #5
    I would use the findings as the primary dx.
    Christina Lee Wagner, CPC, CPC-H

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