EmailAdmission for combined gastroscopy and colonoscopy (day only procedure)
Publication Date: March 2010
ICD 10 AM Edition: Sixth edition
Retired Date: 30/6/2015
Query Number: 2522
Patient admitted for gastroscopy to investigate abdominal pain and colonoscopy to follow up previous polyps.
Gastroscopy - Abdominal pain, HH (no causal link documented)
Colonoscopy - No polyps found , internal haemorrhoids noted
Would the correct codes be:
R10.4 Other and unspecified abdominal pain
K44.9 Diaphragmatic hernia without obstruction or gangrene
Z09.x Follow-up examination after treatment for conditions other than malignant neoplasms
Z87.12 Personal history of colonic polyps
I84.2 Internal haemorrhoids without complication
and procedure codes
or would you NOT code I84.2, as the colonoscopy was for follow up and you would follow ACS 2113 Follow-up examinations for specific disorders?
Do you apply only one standard ACS 0046 Diagnosis selection for same-day endoscopy to the entire episode, or do you apply two different standards - ACS 0046 for the gastroscopy and ACS 2113 for the colonoscopy.
Are these standards mutually exclusive?
These standards dictate how you approach the medical record, unlike specialist standards that deal with particular diagnoses.
What if the documentation was reversed and the follow-up for the polyps was first mentioned?
Remembering that when you translate codes back into medical statements you should be able to see what happened during that episode of care, would only applying one standard cause vital information to be missed?
Gastroscopy - Abdominal pain, HH (no causal link documented)
Colonoscopy - No polyps found , internal haemorrhoids noted
Would the correct codes be:
R10.4 Other and unspecified abdominal pain
K44.9 Diaphragmatic hernia without obstruction or gangrene
Z09.x Follow-up examination after treatment for conditions other than malignant neoplasms
Z87.12 Personal history of colonic polyps
I84.2 Internal haemorrhoids without complication
and procedure codes
or would you NOT code I84.2, as the colonoscopy was for follow up and you would follow ACS 2113 Follow-up examinations for specific disorders?
Do you apply only one standard ACS 0046 Diagnosis selection for same-day endoscopy to the entire episode, or do you apply two different standards - ACS 0046 for the gastroscopy and ACS 2113 for the colonoscopy.
Are these standards mutually exclusive?
These standards dictate how you approach the medical record, unlike specialist standards that deal with particular diagnoses.
What if the documentation was reversed and the follow-up for the polyps was first mentioned?
Remembering that when you translate codes back into medical statements you should be able to see what happened during that episode of care, would only applying one standard cause vital information to be missed?
Response
The VICC advises that the standards are not mutally exclusive and therefore ACS 2113 Follow-up examinations for specific disorders applies for the colonoscopy and ACS 0046 Diagnosis selection for same-day endoscopy applies for the gastroscopy in the case cited.
When applying ACS 2113, any additional findings must meet ACS 0002 Additional diagnoses before being coded, therefore I84.2 Internal haemorrhoids without complication would not be coded in this scenario.
If the documentation were reversed and follow up for polyps was first mentioned, the follow up would be coded first, presuming it is documented on the discharge summary as per VICC # 2484 Principal diagnosis selection - first mentioned.
When applying ACS 2113, any additional findings must meet ACS 0002 Additional diagnoses before being coded, therefore I84.2 Internal haemorrhoids without complication would not be coded in this scenario.
If the documentation were reversed and follow up for polyps was first mentioned, the follow up would be coded first, presuming it is documented on the discharge summary as per VICC # 2484 Principal diagnosis selection - first mentioned.
