Gastroenterology Coding Alert
List Definitive Reflux Dx When Doc Gives Details
Question: An established patient presented with difficulty swallowing. My gastroenterologist performed a level-three E/M service and decided to perform an esophagoscopy with balloon dilation. He determined that the patient has esophageal reflux. Should I use the same diagnosis codes for the E/M service and esophagoscopy? Iowa Subscriber Answer: You will not use the same diagnosis for the E/M service and the esophagoscopy procedure. You should link the preoperative diagnosis, 787.24 (Dysphagia, pharyngoesophageal phase), to the E/M code 99213 (Office or other outpatient visit for the evaluation and management of an established patient...) since you do not know any more complete diagnosis at that time. Then, link the postoperative diagnosis, 530.81 (Other specified disorders of esophagus; esophageal reflux), to the esophagoscopy code (43220, Esophagoscopy; rigid or flexible; with balloon dilation [less than 30 mm diameter]). Tip: If you only read the pre-op or post-op diagnoses and the type of operation the physician performed, you can easily miss details and other billable services the doctor did not include in the summary.
Gastroenterology Coding Alert
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