tci General Surgery Coding Alert - 2022 Issue Q4

Reader Questions: Don’t Code What’s Not Documented

Question: We have an op note that states “patient presents with sharp stomach pain.” The surgeon performed an endoscopy and diagnosed a “duodenal ulcer.” The notes are sparse with no mention of whether the condition is acute or chronic. There’s no evidence of a biopsy with an H. pylori test for the ulcer diagnosis. The surgeon says he’s unable to provide additional information. How should we code the diagnosis? Texas Subscriber Answer: You were correct to query the surgeon regarding details of the case. Accurately coding an ulcer would require knowing whether the...

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