Gastroenterology Coding Alert

Question: Our gastroenterologist referred a patient to a radiologist for an abdominal CT scan because of abdominal pain. The test came back normal. How should I report this?

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Answer: If the diagnostic test does not provide a definitive diagnosis, or if it came out with normal results, you should code the sign or symptom that prompted the treating physician to order the study. In this case, you’ll need to report a code from the R10.0 (Acute abdomen) category to report the symptom your provider documented. You’ll need to go back to the documentation for details to determine the full reportable code based on the pain’s location.

If the diagnostic test was normal, but the referring physician records a suspected (a.k.a. probable, suspected, questionable, rule out, or working) diagnosis, report the presenting signs and symptoms. The Section I.C.21.c.5 of the ICD-10-CM guidelines warn, “The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.” For instance, suppose the physician’s notes indicated “suspected blockage of a bile duct by gallstones,” but the CT scan came out normal. You would report the specific symptom, such as R10.13 (Epigastric pain), as the reason for the test.

Remember: Section I.B.5 of the ICD-10-CM guidelines say, “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.” Then section I.B.6. goes on to state that “Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.”