Gastroenterology Coding Alert

Question: I'm preparing a documentation checklist for endoscopy. What information should I include?

California Subscriber

Answer: Here are the things you should remember when coding for gastrointestinal endoscopy (43235- 43259):

• You should describe multiple polyps and lesions by indicating the location and treatment method for each one.
• You must provide pre-op and post-op diagnosis, or use the pre-op diagnosis twice if there were no findings.

If the patient has anemia (285.9, Anemia, unspecified), you should document a more specific anemia diagnosis since some payers won't accept the "unspecified" code to support colonoscopy or EGD.

If family history of colorectal cancer triggered a colonoscopy, you should document which family member or members (sibling, parent, or child).