Gastroenterology Coding Alert

Question: When the gastroenterologist refers a patient to a radiologist for an abdominal CT scan with a symptom of abdominal pain, both the radiologist — when reporting for the technical component of the CT scan — and the gastroenterologist — when reporting for the follow-up E/M visit for the same test — might report a diagnosis such as “intra-abdominal abscess.” However, what should you do if the diagnostics come out normal?

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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. Say the CT scan results came back without any abnormal findings, then you would report the symptom (the abdominal pain) instead of a definitive diagnosis such as K65.1 (Peritoneal abscess).

If the diagnostic test was normal, but the referring physician records a suspected (a.k.a. probable, suspected, questionable, rule out, or working) diagnosis, you should not code the referring diagnosis. Instead, you should again report the presenting signs and symptoms. 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. Again, you would report the symptom, such as R10.9 (Unspecified abdominal pain) rather than the suspected condition as the reason for the test.

Keep in mind: If the patient is receiving only diagnostic services during the outpatient visit, you would list first the condition that is the main reason for the visit on the claim. This code should be your primary diagnosis. Then, you would code for other diagnoses (such as chronic conditions) on the following lines. For example, say a patient with chronic gastritis got the CT scan, and test results revealed the presence of a peritoneal abscess. On your claim you should list K65.1 as your primary diagnosis and K29.40 (Chronic atrophic gastritis without bleeding) as your secondary diagnosis.

Remember: “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification,” state the 2022 ICD-10-CM Official Guidelines for Coding and Reporting, which went into effect on October 1, 2021. “Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present,” the guidelines note.