Wiki Dx code sequencing-Findings 1st or last?

[bridgettemartin]

I have a question about an article in the October issue of The Coding Edge, related to dx coding for therapeutic procedures. The article states for CPT code 45380, "symptoms are sequenced first, and findings last". I am curious to know if others code the indications first and the findings second. I was taught to code the findings first, then the indications for the procedure.
For instance: Colon scheduled for diarrhea. He found inflammation of the colon and took bx. Path report shows colitis.
45380 - 558.9/787.91
vs:
45380 - 787.91/558.9

Thanks for your input, and if you have any links to published articles about this topic they would be greatly appreciated!

 

[chewri]

code problem or findings 1st

I was taught for commercial insurance you code the reason for the procedure 1st. For Medicare, what was found 1st so will be interesting to have other input on this question.

 

[mitchellde]

Coding guidelines state that unless a specific chapter states different, you code only the definitive diagnosis, or the symptom you do not code both, unless the documentation states the symptom is related to something else and the finding is incidental.

 

[bridgettemartin]

Coding guidelines state that unless a specific chapter states different, you code only the definitive diagnosis, or the symptom you do not code both, unless the documentation states the symptom is related to something else and the finding is incidental.

Debra,
Our providers rarely state in their op-note whether or not the finding is the cause of the symptom. Like in this case, diarrhea is the indication. The endoscopic finding is inflammation, and the path states colitis. It is never stated that the path finding of colitis is the cause of the diarrhea. Would the diarrhea be sequenced first? Only? Add the 558.9?
Thanks!

 

[mitchellde]

if the provider does not give any further information one can assume that the colitis is the definitive finding and uyyou would code only the colitis. The provider would need to specify that the diarrhea is still beingf investigated and indicate that the colitis is an incidental finding for you to code both, if that were the case you would code the diarrhea first since incidental findings are always secondary. But with the information you have provided, code only the colitis.