Gastroenterology Coding Alert

Tip: Separate codes apply to dyspepsia symptoms.

Heartburn, also known as pyrosis or waterbrash, usually poses as a symptom of Gastroesophageal reflux disease (GERD). The chest pain caused by GERD has a distinct 'burning' sensation, occurs after eating or at night, and worsens when a person lies down or bends over. Presently, you report heartburn using the ICD-9 code 787.1 (Heartburn).

ICD-10 difference: When ICD-9-CM shifts to ICD-10-CM in Oct. 1, 2013, code 787.1 will change to R12 (Heartburn). Bearing the same descriptor, you will treat your R12 the same way as you do ICD-9 787.1.

Documentation: According to ICD-10-CM, R12 will exclude dyspepsia NOS, which you would report with R10.13 (Epigastric pain), and functional dyspepsia, which you should code as K30 (Functional dyspepsia).

Coding tips: A new patient presents with complaints of heartburn and difficulty swallowing. Because of the symptoms the patient exhibits, the physician decides a complete evaluation is necessary to devise a treatment plan. After providing a level-four E/M service, the gastroenterologist decides to perform a diagnostic endoscopy on the same day as the visit. On the claim, you would report 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) for the endoscopy; and 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of moderate complexity.) for the E/M, appended by modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Then link R12 and R13.10 (Dysphagia, unspecified) to 43235 and 99204.