Gastroenterology Coding Alert

Question: A patient who was scheduled for a gall bladder surgery presented for a pre-op evaluation. The physician listed the condition prompting the surgery as acute cholecystitis (K81.0) and the underlying medical condition as diabetes (such as E11.9, Type 2 diabetes mellitus without complications). Our office manager says we should also use a “Z” code with the claim but we aren’t certain which one applies.

Arizona Subscriber

Answer: Sometimes, a physician might order a diagnostic test in the absence of signs and symptoms, or perform a preop evaluation for the patient. 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.

Therefore, in this case, you’ll list Z01.818 followed by K81.0 and then E11.9.