tci General Surgery Coding Alert - 2024 Issue Q3

You Be the Coder: Surgeon’s Work Determines Diagnosis Code

Question: The surgeon took a tissue sample from the esophagus during an esophagogastroduodenoscopy (EGD) for a patient diagnosed with gastroesophageal reflux disease (GERD), but there was no evidence of any bleeding in the esophagus. The pathology report noted “inflammation and reactive changes to the squamous mucosa.” What are the appropriate procedure and diagnosis codes for this case? Wyoming Subscriber Answer: The pathology report confirms the presenting diagnosis of GERD, and there is no evidence of any separate or distinct diagnosis based on the findings. That means you should code GERD as the diagnosis. Because the surgeon does...

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