Gastroenterology Coding Alert

Hint: The existence or lack of bleeding is still the final key to right code selection.

If you’re reporting chronic gastritis diagnosis after Oct.1, 2014, be ready to scrutinize documentation minutely --- you will need to focus on lab findings to check extent of disease progress as it is going to influence the ICD-10 code that you will choose to report the condition.

Observe the Presence or Absence of Bleeding to Select Code in ICD-9

When your gastroenterologist makes a diagnosis of chronic gastritis, you will have to report the condition using one of the two codes that are available. So, you will report either 535.10 (Atrophic gastritis [without hemorrhage]) or 535.11 (Atrophic gastritis with hemorrhage) depending on the presence or absence of bleeding. However, you will also report the same set of codes for atrophic-hyperplastic gastritis. Also, there is no proper code set to identify between chronic superficial gastritis and atrophic gastritis.

Look for Progress of Condition in ICD-10

Once you begin using ICD-10 codes, a diagnosis using 535.1x will crosswalk to the parent code K29 (Gastritis and Duodenitis). For chronic gastritis, you have more reporting options as ICD-10 code sets is more elaborate in identifying the type. When your gastroenterologist diagnoses chronic gastritis, you will report from one of the following codes using ICD-10:

·         K29.3 – Chronic superficial gastritis

·         K29.4 – Chronic atrophic gastritis

·         K29.5 – Unspecified chronic gastritis

As in ICD-9, each of the above mentioned codes uses an additional expansion depending on the presence or absence of bleeding. For example, K29.3 further expands to K29.30 (Chronic superficial gastritis without bleeding) and K29.31 (Chronic superficial gastritis with bleeding). If your gastroenterologist arrives at a diagnosis of chronic superficial gastritis with bleeding, you will report K29.31.

Reminder: If your gastroenterologist diagnoses gastric atrophy, you will either choose K29.40 (Chronic atrophic gastritis without bleeding) or K29.41 (Chronic atrophic gastritis with bleeding) depending on presence or absence of hemorrhage. You can choose between K29.50 (Unspecified chronic gastritis without bleeding) and K29.51 (Unspecified chronic gastritis with bleeding) when the diagnosis is chronic antral gastritis or chronic fundal gastritis again basing the final selection on the existence of bleeding.

Note Down These Basics Briefly

Documentation spotlight: When your gastroenterologist arrives at a diagnosis of chronic gastritis, some of the signs and symptoms that you are most likely to see in the documentation of the patient will include epigastric tenderness, bloating, abdominal pain and bad breath. Although some of these signs and symptoms might be present and might help your gastroenterologist point towards a diagnosis of gastritis, your clinician will need to perform lab studies and endoscopy with biopsy to arrive at a definitive diagnosis including the extent of the condition.

So to arrive at a final diagnosis, your gastroenterologist will perform an upper EGD with biopsy taking tissue samples from varied sites of the antrum, corpus and incisura. These samples will then be studied histologically to arrive at a definitive diagnosis.

Example: Your gastroenterologist assesses a 60-year-old male patient who has been suffering from frequent episodes of abdominal pain and bloating for many months. Upon examination, your gastroenterologist notes the presence of epigastric tenderness and also mentions the presence of halitosis in the documentation.

A guaiac-stool test conducted arrives positive for occult blood. Suspecting gastritis, your gastroenterologist then performs an upper EGD with biopsy and removes samples from various sites and sends them to the lab for analysis. Lab results arrive positive for H. pylori and histological examination shows atrophy.

What to report: You will have to report the guaiac-stool test using 82272 (Blood, occult, by peroxidase activity [e.g., guaiac], qualitative, feces, 1-3 simultaneous determinations, performed for other than colorectal neoplasm screening). The upper EGD performed by your gastroenterologist will have to reported using 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple). Since descriptor for 43239 states “single or multiple,” you’ll use only unit of 43239 even though your gastroenterologist extracts multiple biopsy samples from various areas of the stomach.

You report 535.11 if you are using ICD-9 codes and K29.41 if you are using ICD-10 codes. You’ll have to choose these two codes as the result of the guaiac-stool test was positive indicating the presence of bleeding.