Anesthesia Coding Alert

Code Dysphagia First, Then Existing Cancer

 Question: A patient underwent esophagoscopy esophageal dilation and esophageal stent placement. The physician wrote "dysphagia" as the diagnosis. When I checked hospital records, the patient had cancer in her lower esophagus. How should I code the procedure and diagnosis?

Maryland Subscriber


Answer: For the diagnosis, report 787.2 (Dysphagia). If you can verify the cancer diagnosis, you can also report it with 150.5 (Malignant neoplasm of esophagus; lower third of esophagus) as a secondary diagnosis.
 Code the procedure with 00740 (Anesthesia for upper gastrointestinal endoscopic procedures, endoscope introduced proximal to duodenum).