Gastroenterology Coding Alert

Question: A patient who is scheduled for a cholecystectomy came to our office for a pre-operative evaluation. The physician listed the condition prompting the surgery as acute cholecystitis (K81.0) and the underlying medical condition as diabetes E11.9, (Type 2 diabetes mellitus without complications). Should we report the screening code or the ICD-10 code for the specific diagnosis?

Tennessee Subscriber

Answer: Sometimes, a physician might order a diagnostic test in the absence of signs and symptoms, or perform a preoperative evaluation for the patient to confirm that they are healthy enough for the procedure. If the chief reason for the encounter is a preop evaluation, list first a code from category Z01.818 (Encounter for other preprocedural examination) to describe the preop evaluation. Then, assign a code for the condition prompting the surgery as an additional diagnosis (in this case, K81.0). Any condition discovered during the screening should be reported as additional diagnosis codes.

Z codes take the spotlight, too, when a patient has no signs or symptoms and the gastroenterologist performs a test solely for screening purposes. In this case, you should disregard typical diagnosis codes and locate an applicable Z code to describe the test to the payer.

Other technicalities: List the screening code first if the reason for the visit is specifically the screening exam. Report the screening code as an additional code, however, if the physician performs the screening during an office visit for other health problems. Additionally, if the screening returns an abnormal result, then code those results as an additional diagnosis.