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tci General Surgery Coding Alert - 2022 Issue Q3

You Be the Coder: Surgeon May Have Final Say in Dx Coding

Question: The surgeon submitted an esophageal biopsy taken during an esophagogastroduodenoscopy (EGD) with no mention of esophageal bleeding for a patient diagnosed with GERD. The pathology report noted “inflammation and reactive changes to the squamous mucosa.” What are the procedure and diagnosis codes for this case? Georgia Subscriber Answer: You should code from the pathology report when the findings provide a definitive diagnosis. But in this case, the pathology findings are consistent with the presenting diagnosis of gastroesophageal reflux disease (GERD) and do not point to a separate diagnosis. That means you should code the GERD as...

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