How Should I Report Barrett’s Esophagus With or Without Dysplasia?
Question: Our gastroenterologist frequently screens patients with chronic gastroesophageal reflux disease (GERD) symptoms for Barrett’s esophagus. I’m unsure how to choose the correct diagnosis code, especially if dysplastic changes are noted. Can you walk me through how to accurately report this? Georgia Subscriber Answer: Great question, and one that’s especially important because ICD-10-CM allows for greater specificity when reporting Barrett’s esophagus. Let’s walk through how you should approach coding based on clinical findings, especially regarding dysplastic changes. Patients with longstanding or severe GERD symptoms — such as heartburn (R12 [Heartburn]), dysphagia (R13.10 [Dysphagia, unspecified]), or gas pain (R14.1 [Gas pain]) — may be at risk of developing Barrett’s esophagus. If your gastroenterologist suspects Barrett’s, they may order an upper gastrointestinal (GI) endoscopy to visually inspect the esophagus and collect a biopsy if needed. If the gastroenterologist sees concerning findings (like salmon-colored mucosa or inflammation in the lower esophagus), they’ll typically perform a biopsy during the endoscopy; in that case, you should report the procedure with 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple). Notice how this code is different from 43235 (… diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)), which does not include a biopsy. Once the pathology results return, review the provider’s documentation and lab report for any mention of dysplasia. ICD-10-CM allows you to capture whether dysplastic changes are present, and if so, the grade. Here’s how to break it down: No dysplasia? Use K22.70 (Barrett’s esophagus without dysplasia). Dysplasia present? Start with K22.71- (Barrett's esophagus with dysplasia), and then look deeper for grade: Documentation tip: Don’t just rely on the initial diagnosis. Always check the pathology report for any indication of dysplasia and verify that the provider documents the findings and assigns a diagnosis in the medical record accordingly. Coding for Barrett’s esophagus under ICD-10-CM requires close attention to the documentation and pathology. Don’t default to K22.7- (Barretts’s esophagus) unless you’ve verified that no more specific code applies. Always clarify with your provider if dysplasia or its grade isn’t clearly stated in the record. Suzanne Burmeister, BA, MPhil, Medical Writer and Editor
