Gastroenterology Coding Alert

Question: What diagnosis code should I use when the doctor's notes state that the patient had an abnormal biopsy from a previous EGD and the repeat biopsy to rule out any significant problems?

Washington Subscriber

Answer: First, you should request more information from the physician. Explain to him that this is not a specific preoperative or postoperative diagnosis. If the physician cannot give you more details, you should attempt to locate the previous pathology report and see what the abnormal findings were. If all else fails, you can use code 793.4 (Nonspecific abnormal findings on radiological and other examination of body structure; gastrointestinal tract).

Clinical and coding expertise for You Be the Coder and Reader Questions provided by Linda Parks, MA, CPC, CCP, coding specialist at GI Diagnostics Endoscopy Center in Marietta, Ga; and Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the CPT advisory panel.