Gastroenterology Coding Alert
Reader Questions:
Know How to Code for Normal Diagnostic Findings
Published on Mon Feb 27, 2023
Question: Our gastroenterologist referred a patient to a radiologist for an abdominal CT scan with abdominal pain, however, the diagnostics came back normal. How should I code this at the follow-up evaluation and management (E/M) visit? Nevada Subscriber Answer: This is a common situation that understandably baffles coders. With no diagnosis, it’s easy to second-guess yourself. If the diagnostic test did not provide a definitive diagnosis, or came back with normal results, simply code the sign or symptom that prompted the treating physician to order the study in the first place. In the case you described, that would mean you’d report R10.9 (Unspecified abdominal pain).
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Know How to Code for Normal Diagnostic Findings
Question: Our gastroenterologist referred a patient to a radiologist for an abdominal CT scan with abdominal [...]
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