General Surgery Coding Alert
List Most Specific Diagnosis
Question: A primary care physician referred a patient suffering from symptoms such as a cough, heartburn, and acid stomach for our surgeon to perform an EGD to rule-out GERD. What diagnosis should we report? Codify Subscriber Answer: That depends on the findings. For instance, if the surgeon notes esophagitis during the esophagogastroduodenoscopy (EGD) procedure and the clinician affirms a diagnosis of gastro-esophageal reflux disease (GERD) based on clinical and surgical findings, you can report K21.0 (Gastro-esophageal reflux disease with esophagitis). Remember: You should always wait for the path report or other definitive diagnosis after the procedure to properly code the diagnosis. If the procedure doesn't result in a definitive diagnosis, then you should code the signs and symptoms that were the reason for the procedure. In this case, the signs and symptoms that led to the request for an EGD procedure were among the following: Other symptoms that might trigger an EGD order include these symptoms: Important: These symptoms can sometimes also be caused by cardiac or pulmonary problems, so make it a point to report any pre-existing chronic conditions and habits that may exacerbate GERD such as asthma (J45.-), obesity (E66.-), smoking, pregnancy and hereditary predisposition.
Related Articles
General Surgery Coding Alert
- CCI Update:
Master Version 24.0 Edits for Your Surgery Practice
Stay compliant with claims-filing rules. With loads of new CPT® codes effective in January, you [...] - CCI Edits:
Galvanize Bundling Rules with Resources and Documentation
Know your payer's expectations. Although Correct Coding Initiative (CCI) bundles indicate which CPT® and HCPCS [...] - ICD-10:
Capture Underlying HIV Condition for Surgical Report
Alert payers to possible complications. When your surgeon performs a procedure on a patient with [...] - HIV Coding Quiz:
Gauge Your Answers Against the Experts'
Report AIDS in narrow circumstances. Making errors when reporting human immunodeficiency virus, acquired immunodeficiency syndrome [...] - Reader Question:
Nail Down Method and Reason for Colonoscopy Code
Question: Our surgeon documented a colonoscopy for a 62-year-old female patient who had a positive [...] - Reader Question:
Get Hemorrhoid Coding Right
Question: The surgeon performed a flexible sigmoidoscopy for a patient who presented with rectal bleeding. [...] - Reader Question:
Check CCI for 2 Scopes
Question: Our surgeon performed a colonoscopy, removing one polyp, but he also documented a submucosal [...] - Reader Question:
Look Ahead to Appropriate Use for Imaging
Question: To comply with the CMS rule about appropriate use for imaging, we recently added [...] - Reader Question:
List Most Specific Diagnosis
Question: A primary care physician referred a patient suffering from symptoms such as a cough, [...]
