Wiki Abdominal Pain or Disease of Gallbladder?

[MichelleAKing]

Dear All:
The patient comes into the office with abdominal pain (RUQ), the encounter note is regarding the abdominal pain, yet the physician codes the visit as disease of gallbladder. A the end of the note it may say something like "probably biliary diskenesia". We have been getting denails on these visits so I make sure that I always send the code as abdominal pain. The physician is upset that his codes have been changed. I tried to explain to him that without test results documented specifically stating that the patient has gallbladder disease that I can't code it that way. He said that in order for him to take the patient to surgery it can't be just coded as abdominal pain, and I understand what he's saying, however, I am basing my findings on the signs and symptoms. Does anyone have anything regarding coding "rule outs", "probable finding" etc.? I would greatly appreciate it as I have to make my case. Thanks in advance!
~Michelle

 

[Michele Hannon]

ID-9-CM
Introduction
Section IV Diagnostic Coding and Reporting Guidelines for Outpatient Services
(includes provider based office visits)

I. Uncertain diagnosis
Do not code diagnoses documented "probable", "suspected", "questionable", "rule out" or "working diagnosis" or other certain terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reasons for the visit.

Good Luck!

 

[syllingk]

biliary dyskenisia would have to be documented by a hida scan. Are there no tests whatsoever to fall back on? US? No known pathology like stones? Then he is out of luck and can only do the signs and symptoms.

 

[BEARDOG]

There is no code for "rule out", "possible", "probable" or "i think it might be"...You can only code what the documentation shows as a definite symptom or problem. In the situation you are describing the only definite diagnosis you have is abdominal pain. And if you will check the ICD 9 cross codes allowed with 47562 (I use Ingenix to check cross codes) 789.01 RUQ abd pain, 789.06 epigastric abdominal pain, 789.07 generalized abd pain and 789.09 abd pain, other spec site are all covered codes for a laparoscopic cholecystectomy. There is nothing wrong with using abdominal pain as the diagnosis code for a cholecystectomy. I hope this was helpful for you.

Debbie A-CPC, CGSC