Gastroenterology Coding Alert

Your physician should document if patient has esophagitis.

When coding for a motility manometric study that discovers esophageal reflux, you would likely report 530.81 (Diseases of esophagus; other specified disorders of esophagus; esophageal reflux) to describe a diagnosis for the test claim. When ICD-9 becomes ICD-10 in 2013, you will have to shift to coding either K21.0 (Gastro-esophageal reflux disease with esophagitis) or K21.9 (Gastro-esophageal reflux disease without esophagitis) for the diagnosis.

ICD difference: 530.81 will expand into two codes K21.0 and K21.9 when ICD-10 takes effect on October 1, 2013. The ICD-10 code specifically defines gastro-esophageal reflux disease (GERD) and indicates the presence or nonpresence of esophagitis.

Physician documentation: Notice the difference between K21.0 and K21.9, which depends on whether the test revealed that the patient has esophagitis. You should be on the lookout for any mention of this in your physician's notes.

Keep in mind, however, that esophagitis is a visible or histologic finding that can't be concluded without an endoscopic exam. You might be able to choose other more appropriate codes from ICD-10 for patients that have not had endoscopy.

Coder tips: GERD is coded 530.81 in ICD, but in ICD-10 more details are required. The user needs more information, such as whether the GERD is with or without esophagitis.