Gastroenterology Coding Alert

Here's a handy reference for when your gastroenterologist dictates an endoscopy report.

If patient had multiple polyps or lesions, describe location and treatment method for each one.

"Multiple polypectomies" does not give your coder enough information.

Provide both pre-op and post-op diagnoses. If there were no findings, use the pre-op diagnosis twice.

Document a specific anemia diagnosis, if appropriate. Most Medicare payers won't accept 285.9 (Anemia, unspecified) to support colonoscopy or EGD.

If the patient had a screening colonoscopy due to family history of colorectal cancer, document which family member or members. Must be sibling, parent or child to qualify.

If you used a templated electronic health record, make sure descriptions actually match what was performed. If there were differences, add notes of explanation to prevent coding errors.