Gastroenterology Coding Alert

Watch out for these phrases in your physician's documentationYour first line of ICD-9 coding is to attach signs or symptoms to your claim, but even after your gastro-enterologist performs a diagnostic test, you will only sometimes report a definitive diagnosis.Strategy: By answereing four important questions, you'll avoid applying a definitive diagnosis prematurely -- which can have long-standing consequences for a patient and the patient's insurance.Danger: "If you apply a diagnosis for colon cancer and the biopsy comes back negative for cancer, you have now given that patient a condition he or she doesn't have -- and it's next to impossible to get that corrected with insurance companies," says Susan Pryzeski, practice manager for Specialists in Gastroenterology in Elgin, Ill.What Do Signs and Symptoms Entail?Get this straight: In the absence of a definitive diagnosis, you should report signs and symptoms to support medical necessity for services your gastroenterologist provides.ICD-9 guidelines stipulate that you should apply signs-and-symptems diagnoses if::
 • The physician cannot make a more specific diagnosis, even after he has investigated all the facts bearing on the case.
 • Signs or symptoms existing at the time of the initial encounter that proved to be transient and whose causes could not be determined.
 • Provisional diagnoses in a patient who failed to return for further investigation or care.
 • Cases referred elsewhere for investigation or treatment before the physician could make a diagnosis.
 • Cases in which a more precise diagnosis was not available for any other reason.
 • Certain symptoms that represent important problems in medical care and that the physician might wish to classify in addition to a known cause.Gastro highlights: Some signs and symptoms you might see in a gastroenterologist's documentation include: abdominal pain (789.01��"789.09); appetite loss (783.0); fluid in the abdominal cavity, or ascites (789.5); unspecified chest pain (786.50); diarrhea, not otherwise specified (787.91); dysphagia (787.2); flatulence (787.3); heartburn (787.1); incontinence, feces (787.6); nausea alone (787.02), and; nausea with vomiting (787.01).Example: During an initial consult with a new patient, a gastroenterologist suspects a diagnosis of Crohn's disease (555.9). How should you report this?Answer: Until testing or diagnostic services confirm the Chron's diagnosis, you should rely on signs and symptoms to justify medical necessity for any services the physician provides.Typical signs and symptoms indicative of Crohn's disease include abdominal pain/cramping (789.0X, Abdominal pain), diarrhea (787.91), fever (780.6), loss of appetite (783.0, Anorexia) and rectal bleeding (579.3, Hemorrhage of rectum and anus).Will I Always Report a Definitive Dx After a Procedure?You should report a definitive diagnosis when your gastroenterologist has performed a procedure and the results confirm it. In other words, "you should never assign a diagnosis until its definitive," says Doris Ward, CPC, coder/biller at KY Surgery Center in Lexington.Example: The gastroenterologist conducts colonoscopy [...]