dx code sequencing

Pt came in for EGD with abd pain and nausea. Biopsies were performed for abd pain. Hiatal hernia was found. Would it be correct to code abd pain first since that was the reason for biopsy? Or, would it be correct to code hiatal hernia first since its the only "definitive" diagnosis? I am being given conflicting information and need clarification.

Thanks!

re: dx code sequencing

If test were performed and you have a definitive diagnosis you would bill that with dx, the only time that you would bill for the sign and symptoms is when you do not have a definitive DX and you are awaiting confirmation from the labs. This is per the ICD-9 guidelines. hope that helps clarify the conflictioning information.

re: dx code sequencing

lkwilliams is exactly correct.

re: dx code sequencing

Thank you petunia for that response, its always nice to know that the informaton that is offered here, btw, free of charge! is appreciated:)

re: dx code sequencing

Agreed... I am so happy that there are people who are willing to take the time as a volunteer to help someone else out. :)

re: dx code sequencing

The hiatal hernia is being referred to as an incidental finding. Does that make a difference? Thanks so much for all the replies. I am fairly new to this and need all the help i can get:)

re: dx code sequencing

since you have a definitive DX, I would stick with that, you are describing the medical neccessity of a procedure and facilitating prompt payment for the health services provided. Again per ICD-9, if symptoms are present but a definitive dx has been determined code for that, if not code the symptoms. if however the provider is coding for higher level of E&M and has documetation and medical neccessity to support it, you can use also the signs and symptomsto help support the higher level of E&M. Since you are new to this and if you have an ICD-9 book, i suggest you read the ICD-9 guidelines on "How to Use the ICD-9 volumes, its located in the front of the book, it is a great way to understand how to use the diagnosis codes throughout the book, good luck:)