Wiki Coding inconclusive dx vs. signs and symptoms

[jojogi]

I have a question regarding coding inconclusive findings on a PATH report vs. coding the indication. A person came in for an GI surgical procedure and the indication says "melena and rectal bleeding". A biopsy was done and the PATH report came back with "Fragment of unremarkable stomach mucosa". Would I code an unspecified code (537.9) as the primary with the signs and symptoms as secondary diagnoses or would I code the signs and symptoms only. I think I would code the findings, even though they are unspecified, but have been told to code it otherwise. Any input would be great!

Thanks

 

[mitchellde]

signs and symptoms only the specimen was unremarkable so there is no diagnosis to code there. 537 is the category for disorders of stomach and duodenum and clearly this patient does not have this diagnosis.
It is not an unspecified finding, the finding is there is no problem and that is very different. Also if there were a definitive diagnosis then you would not code the symptoms. In this scenario, code the symptoms.

 

[jojogi]

signs and symptoms only the specimen was unremarkable so there is no diagnosis to code there. 537 is the category for disorders of stomach and duodenum and clearly this patient does not have this diagnosis.
It is not an unspecified finding, the finding is there is no problem and that is very different. Also if there were a definitive diagnosis then you would not code the symptoms. In this scenario, code the symptoms.

Thank you!