Gastroenterology Coding Alert

Question: A primary-care physician (PCP) sent a patient to us for a consultation. The request included an outline of symptoms, which included intense heartburn and abdominal pain. The PCP is concerned that the patient has reflux disease. We conducted the consult and performed a diagnostic endoscopy. We didn't find anything wrong with him. Which diagnosis code should we use?

Kansas Subscriber

Answer: You should code the patient's symptoms only. Please refer to the "Symptoms, Signs, and Ill-Defined Conditions" section of ICD-9 (780-799). In this case, use 787.1 (Heartburn) and 789.00 (Abdominal pain; unspecified site).
- The PCP's concern about the patient having reflux disease has no bearing in this case -- at least in terms of the diagnosis coding -- because the gastroenterologist found no evidence to support that diagnosis.

-- Clinical and coding expertise for this issue provided by Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel; and Linda Parks, MA, CPC, CMC, CMSCS, an independent coding consultant in Atlanta.