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Gastroenterology Coding Alert

Reader Question:

Signs, Symptoms and E Codes - Oh My

Published on Sun Aug 31, 2003

Question: A primary-care physician (PCP) sent a patient to us for a consult. The request included an outline of symptoms, which included intense heartburn and abdominal pain. The PCP is concerned that the patient has reflux disease. We conducted the consult and performed a diagnostic endoscopy. We didn't find anything wrong with him. Which diagnosis code should we use?

South Carolina Subscriber Answer: You should code the patient's symptoms only. Please refer to the "Symptoms, Signs, and Ill-Defined Conditions" section of ICD-9 (780-799). In this case, use 787.1 (Heartburn) and 789.00 (Abdominal pain; unspecified site).
 
The PCP's concern about the patient having reflux disease has no bearing in this case - at least in terms of the diagnosis code - since the gastroenterologist found no evidence to support that diagnosis.
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