tci General Surgery Coding Alert - 2018 Issue 3

Reader Question: List Most Specific Diagnosis

Question: A primary care physician referred a patient suffering from symptoms such as a cough, heartburn, and acid stomach for our surgeon to perform an EGD to rule-out GERD. What diagnosis should we report? SuperCoder Subscriber Answer: That depends on the findings. For instance, if the surgeon notes esophagitis during the esophagogastroduodenoscopy (EGD) procedure and the clinician affirms a diagnosis of gastro-esophageal reflux disease (GERD) based on clinical and surgical findings, you can report K21.0 (Gastro-esophageal reflux disease with esophagitis). Remember: You should always wait for the path report or other definitive diagnosis after the procedure to properly...

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