Wiki EGD diagnosis

[MSUEEMBRY]

Need your opinion! My doctor does EGD'S at the hospital and the scope report will list the reason/indication the scope is being done at the top of the sheet, example is Moderately severe heartburn, then he will describe the procedure that was performed then he lists his findings, example is gastritis, para-esophageal hiatus hernia.

My question is should I use the reason the scope is being done as the diagnosis or the actual findings? The hospital coding department is questioning some of these because I have used the doctors finding as the diagnosis?

Which should I be using for my diagnosis? The reason he is doing the scope or what he found when he did the scope?

 

[mitchellde]

The guidelines for ICD-10 CM state that if a definitive dx is established by the end of the encounter then use the definitive/ finding dx code, but not both the symptom,and the finding. The ICD-9 CM guidelines say the same thing but ina different way.