Pinpoint the Correct EGD Code for This Gastritis Case
Question: I have an op note for a diagnostic esophagogastroduodenoscopy (EGD) procedure. The patient presented with persistent heartburn and acid reflux lasting longer than two months. The gastroenterologist performed the EGD and reviewed the results. The physician diagnosed the patient with mild gastritis without hemorrhage and prescribed proton pump inhibitors. I’m new to gastroenterology coding — could you help me assign the correct procedure and diagnosis codes? Washington Subscriber Answer: Certainly! Let’s start with the EGD procedure. Use 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)) to report this procedure. The CPT® code set includes multiple EGD codes depending on the provider’s work. Based on what you included in your question, the gastroenterologist performed a diagnostic EGD, which is represented by 43235. If the physician had performed additional actions beyond the diagnostic work, such as therapeutic injections, ultrasound examinations of surrounding structures, or biopsies, then you’d look at the other codes in the 43235-43210 code range. Next, turn to the ICD-10-CM code set to locate the mild gastritis diagnosis code. Open the Alphabetic Index and search for Gastritis (simple). Then, turn to the Tabular List to verify the code. You’ll assign K29.60 (Other gastritis without bleeding) for the documented mild gastritis without hemorrhage diagnosis. Mike Shaughnessy, BA, CPC, Production Editor, AAPC
