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Thread: sign/symptom vs. finding

  1. #1
    Join Date
    Apr 2007

    Default sign/symptom vs. finding

    AAPC: Back to School
    Physician performs GI procedure at hospital, we are responsible for coding the physician service, how should service be correctly coded -

    When a pt has a GI procedure, is it correct to code as first listed the sign/symptom and then the findings or should only the findings be submitted with no sign/symptom.

    Thanks in advance

  2. #2
    Join Date
    Apr 2007
    Louisville, KY


    For Pro fee coding it is ideal to code to the most definitive diagnosis. In other words, if the patient has rectal bleeding as the sign/symptom, but upon completion of the scope found to have bleeding diverticuli, that should be the code reported.

    The situation gets a little strange if the findings of the exam do not explain the sign or symptom. Typically I'm inclined to code solid findings, followed by any unexplained symptom codes. However, I'm sure there's a payer out there who just does not agree with that order.

    Perhaps someone with access to denials or experience in billing can offer more...
    Kevin B. Shields, RHIT, CPCO, CCS, CPC, COC, CCS-P, CPC-P, CPC-I

  3. #3


    We code this situation all the time. If applicable code first the final diagnosis (result) and then the indicated symptoms. If scope is normal with no additional findings then code the most significant symptom for performing the test.

    Its a little different for screening scopes.....
    If screening scope results in biopsy, polypectomy, etc, then code screening diagnosis first and then end diagnosis second but reference the end diagnosis. For example, pt sent for screening colonoscopy (45378) with no signs and symptoms (V76.51), but during scope a benign colon polyp is found and removed by snare. You would bill CPT 45385 and then DX V76.51 first and 211.3 second, and reference (pointer) to 211.3. This is per AGA guidelines for screening.

  4. #4
    Join Date
    Apr 2007


    Thanks to those who provided feedback.

  5. #5

    Default quick question

    Ok, I am hoping maybe you can help me with a quick question somewhat related. I think I know the right answer but I want to make sure my fellow coders agree...

    I am coding for the PCP when doing the H&P in the hospital he DX the patient with GI Bleed, but he ordered an EGD done..

    the report comes back stating she has a duodenal ulcer and peptic ulcer with hemorrhage.

    ok ... so then when it is time with the discharge my dr discharges with the DX of GI Bleed with Peptic Ulcer Diesease.

    Would I code the duodenal & peptic ulcer Primary instead of the GI Bleed?

    The reason I ask... I would code it using the duodenal & peptic ulcer primary.. since it was the cause of the GI Bleed, but there is another coder I work with who thinks maybe I should code the GI Bleed primary.

    Can anyone help me, or make sense of my rambling? HAHA

  6. #6


    The bleed is a symptom of the ulcer. Code as
    533.00 Peptic ulcer, site unspecified, with hemorrhage
    532.30 Duodenal ulcer w/o mention of hemorrhage, perforation or obstruction

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