I am currently coding EGD and colonoscopy procedures. I was trained here at my place of employment to always include the diagnoses listed as indications for the procedure as well as diagnoses found post procedure. I'm finding many times the final diagnoses are inclusive of the symptoms that are listed as reasons for the procedure, but office staff here are insistent that both stay included with insurance claims. Is this correct?
If the post-operative/procedural diagnosis is inclusive of the symptom(s) (e.g., R code) provided as the pre-operative/procedural diagonsis, then you only code the post-operative/procedural diagnosis.
For example, provider orders colonoscopy due to blood in stool (R19.5). Colonoscopy is performed and significant findings include only a large polyp which is excised/biopsied. Because large polyps can cause blood in stool, and there are no other significant findings, then you only code the polyp.
Refer to the following guidelines:
Section IV., K.
K. Patients receiving diagnostic services only
For outpatient encounters for
diagnostic tests that have been interpreted by a physician, and the
final report is available at the time of coding,
code any confirmed or definitive diagnosis(es) documented in the interpretation.
Do not code related signs and symptoms as additional diagnoses.
Section I., B., 4.
4. Signs and symptoms
Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has
not been established (confirmed) by the provider.
(The corollary is that when/if the related definitive diagnosis
has been established (confirmed) by the provider, codes that described symptoms and signs are
not acceptable for reporting purposes. Code to the highest level of specificity when supported by the medical record documentation. A definitive diagnosis is more specific than signs and/or symptoms of a condition/disease.)
Section I., B., 5.
5. Conditions that are an integral part of a disease process
Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.
Final note, IF the colonoscopy or EGD was for a screening, you code the screening code FIRST and then code any significant findings as additional diagnoses. See Chapter 21., c., 5.: “Should a condition be discovered during the screening then the code for the condition may be assigned as an additional diagnosis.”