Wiki GERD and Ulcerative proctitis

[kboyd22]

When a patient is having an EGD performed for an indication of GERD but the exam is normal, would you still use K21.9 or would Z87.19 (personal History of other diseases of the digestive system) be more appropriate?

Also somewhat of the same question on colonoscopy being performed with an indication of "Follow-up of chronic ulcerative proctitis, Disease activity assessment of chronic ulcerative proctitis", but the findings indicate "examination was normal, no active ulcerative colitis". Would an ICD-10 code of K51.20 still be appropriate or should Z09 & Z87.19 be more appropriate?

Thank you for any guidance.

 

[NiteshlalKoyalkar]

Hi
First scenario "When a patient is having an EGD performed for an indication of GERD but the exam is normal, would you still use K21.9 or would Z87.19 (personal History of other diseases of the digestive system) be more appropriate?" in this scenario both the dx K21.9 & Z87.19 will be inappropriate, rather bill Z13.810.

Second scenario "Follow-up of chronic ulcerative proctitis, Disease activity assessment of chronic ulcerative proctitis", but the findings indicate "examination was normal, no active ulcerative colitis". Would an ICD-10 code of K51.20 still be appropriate or should Z09 & Z87.19 be more appropriate? in this case Z09 is appropriate.

Hope this helps