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Gastroenterology Coding Alert

READER QUESTIONS:

Scan Doctor's Notes to Diagnose Repeat Biopsy

Published on Thu Jun 28, 2007

Question: What diagnosis code should I use when the doctor’s notes state that the patient had an abnormal biopsy from a previous esophagogastroduodenoscopy (EGD) and a repeat biopsy to rule out any significant problems?


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Answer: First, you should request more information from the physician. Explain to him that this is not a specific preoperative or postoperative diagnosis.

If the physician cannot give you more details, you should attempt to locate the previous pathology report and see what the abnormal findings were.

If all else fails, you can use 793.4 (Nonspecific abnormal findings on radiological and other examination of body structure; gastrointestinal tract).
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