AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2021 Issue 1; Ask the Editor

Surveillance Upper Endoscopy

A patient undergoes surveillance upper gastrointestinal (GI) endoscopy due to a personal and family history of familial adenomatous polyposis (FAP). The endoscope is introduced into the mouth and after thorough examination of the upper gastrointestinal tract, no evidence of a mass or polyp is found. What diagnosis codes are assigned for a personal and family history of FAP? Is this surveillance endoscopy considered a screening or a follow-up exam? ...

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