Gastroenterology Coding Alert

Note minor changes to the descriptor for Achalasia.

When your gastroenterologist arrives at a diagnosis of achalasia of cardia, you will need to be prepared with the appropriate ICD-10 code to report when these set of codes come into use after Oct. 1, 2014.

Note Descriptor Changes in ICD-10

Under ICD-9 codes, you will report a diagnosis of achalasia using 530.0 (Achalasia and cardiospasm). You can use the same code when your gastroenterologist notes a diagnosis of aperistalsis of esophagus and megaesophagus. The list of exclusions for 530.0 comprises congenital cardiospasm (750.7) and esophageal varices (456.0 -- 456.2).

When ICD-10 codes come into effect, 530.0 in ICD-9 that represents achalasia will crosswalk to K22.0 (Achalasia of cardia). Note that the descriptor in ICD-10 is different to the ICD-9 code for achalasia. The list of inclusions for this code comprise achalasia NOS and cardiospasm while the list of exclusions remain the same as in ICD-9 and includes congenital cardiospasm (Q39.5) and esophageal varices (I85.-)

Observe These Details in the Documentation

Some symptoms that you are most likely to encounter in the patient documentation in a patient suffering from achalasia will include dysphagia (R13.10, Dysphagia, unspecified), pain in the chest (R52, Pain, unspecified), regurgitation and weight loss.

Based on the symptoms, if your gastroenterologist suspects an esophageal obstruction, he will order diagnostic radiological examination such as a barium swallow as it is very helpful in identifying achalasia. He might also opt for a CT scan and ultrasound examination. Another test that your gastroenterologist will undertake if he suspects a diagnosis of achalasia is esophageal manometry.

In addition, your gastroenterologist will perform an esophagoscopy (43200, Esophagoscopy, rigid or flexible; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]) or an upper EGD (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]) to check the reason for the dysphagia.

If your gastroenterologist arrives at a diagnosis of achalasia, he might decide to perform a balloon dilation to stretch the muscle fibers of the lower esophageal sphincter. You report the procedure using 43458 (Dilation of esophagus with balloon [30 mm diameter or larger] for achalasia). Since your gastroenterologist requires the assistance of endoscopy to avoid the risk of perforations, you will have to report 43235 with 43458.

Example: Your gastroenterologist sees a patient with symptoms of severe dysphagia, pain behind the sternum and regurgitation of food. The patient also complains that he has been experiencing sudden weight loss.

Your gastroenterologist performs an upper EGD and notes the presence of food above the lower esophageal sphincter (LES). He orders a barium swallow and performs esophageal manometry (91010, Esophageal motility [manometric study of the esophagus and/or gastroesophageal junction] study with interpretation and report). Based on the results of the tests and the observations noted during the EGD, your gastroenterologist arrives at the diagnosis of achalasia.

He performs a balloon dilation to stretch the muscle fibers of the LES and allow the free passage of food. He performs this procedure with the help of an EGD to prevent perforation of the esophagus. You report the procedures using 43458 and 43235. You report the diagnosis with 530.0 if you are using ICD-9 and K22.0 if you are using ICD-10 set of codes.