tci General Surgery Coding Alert - 2022 Issue Q2

Reader Questions: File Final Dx Code Instead of Symptoms

Question: Our surgeon performed an EGD for a patient complaining of recurrent heartburn, cough, and laryngitis. During the procedure the surgeon identified inflammatory changes in the esophagus and diagnosed the patient with GERD. What diagnosis code(s) should we use for the case? Alabama Subscriber Answer: You should code the final diagnosis, not the presenting signs and symptoms. Because the surgeon doesn’t mention esophageal bleeding, you’ll code the case “without bleeding.” The appropriate code is K21.00 (Gastro-esophageal reflux disease with esophagitis, without bleeding). Similar: You need to ensure that you don’t confuse the code...

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