Gastroenterology Coding Alert

Hint: If cause is alcohol abuse, don’t forget to identify it additionally.

When reporting a diagnosis of gastrojejunal ulcer with ICD-10, you’ll need to focus only on presence or absence of hemorrhage or perforation along with chronicity. You do not have to check for obstruction as you would do when reporting the condition with ICD-9 codes.

ICD-9: When reporting a diagnosis of gastrojejunal ulcer in ICD-9, you start out with the base code 534 (Gastrojejunal ulcer). Then, depending on chronicity, presence or absence of perforation and hemorrhage, you use a 4th digit expansion to report gastrojejunal ulcer using the following 9 codes:

• 534.0 (Acute gastrojejunal ulcer with hemorrhage)
• 534.1 (Acute gastrojejunal ulcer with perforation)
• 534.2 (Acute gastrojejunal ulcer with hemorrhage and perforation)
• 534.3 (Acute gastrojejunal ulcer without mention of hemorrhage or perforation)
• 534.4 (Chronic or unspecified gastrojejunal ulcer with hemorrhage)
• 534.5 (Chronic or unspecified gastrojejunal ulcer with perforation)
• 534.6 (Chronic or unspecified gastrojejunal ulcer with hemorrhage and perforation)
• 534.7 (Chronic gastrojejunal ulcer without mention of hemorrhage or perforation)
• 534.9 (Gastrojejunal ulcer unspecified as acute or chronic without mention of hemorrhage or perforation)

Key: Each of the above mentioned codes will further expand into two codes using a 5th digit expansion, depending on the presence or absence of obstruction.

For example, 534.3 will expand into the following two codes:

• 534.30 (Acute gastrojejunal ulcer without mention of hemorrhage or perforation without obstruction)
• 534.31 (Acute gastrojejunal ulcer without mention of hemorrhage or perforation with obstruction)

ICD-10: When you begin to use ICD-10 codes, 534 in the ICD-9 system of codes will crosswalk to K28 (Gastrojejunal ulcer). You’ll also use the same diagnosis codes when your clinician diagnoses anastomotic ulcer (peptic) or erosion; gastrocolic ulcer (peptic) or erosion; gastrointestinal ulcer (peptic) or erosion; gastrojejunal ulcer (peptic) or erosion; jejunal ulcer (peptic) or erosion; marginal ulcer (peptic) or erosion or stomal ulcer (peptic) or erosion. 

If the cause for the peptic ulcer is due to alcohol abuse, you need to additionally identify it with F10.-. However, you cannot use K28 if the diagnosis is primary ulcer of small intestine.  You will report this with K63.3.

Reminder: As with ICD-9, you will have to further expand K28 to identify the presence or absence of hemorrhage and perforation. However, you will not have to worry about checking for the presence or absence of obstruction as this will not form the basis of choosing the code to report the diagnosis.

Based on hemorrhage and perforation, you’ll have to choose from the following nine expansions to K28:

• K28.0 (Acute gastrojejunal ulcer with hemorrhage)
• K28.1 (Acute gastrojejunal ulcer with perforation)
• K28.2 (Acute gastrojejunal ulcer with both hemorrhage and perforation)
• K28.3 (Acute gastrojejunal ulcer without hemorrhage or perforation)
• K28.4 (Chronic or unspecified gastrojejunal ulcer with hemorrhage)
• K28.5 (Chronic or unspecified gastrojejunal ulcer with perforation)
• K28.6 (Chronic or unspecified gastrojejunal ulcer with both hemorrhage and perforation)
• K28.7 (Chronic gastrojejunal ulcer without hemorrhage or perforation)
• K28.9 (Gastrojejunal ulcer, unspecified as acute or chronic, without hemorrhage or perforation)

Check These Basics Briefly

Documentation spotlight: Some symptoms that you are most likely to encounter in the documentation of a patient suffering from gastrojejunal ulcers might include lower epigastric pain, burning sensation shortly after food consumption, heartburn, dysphagia, dyspepsia, hematemesis, and melena. This condition is relatively rare and may be seen in patients who have had previous surgical procedures. Upon examination, your clinician might note signs of anemia, epigastric tenderness, and guaiac- positive stools caused due to bleeding.

Tests: If your gastroenterologist suspects gastrojejunal ulcers, he’ll order tests to check for H. pylori infections such as a rapid urease test or a breath test. In addition, he may withdraw a blood sample to check for CBC, liver function tests (LFT), lipase and amylase.

He might also ask for an x-ray especially if he suspects perforation of the ulcer. He might also perform an upper EGD to directly visualize the GI tract to check for signs and symptoms of the ulcer and to check for complications.

Example: Your gastroenterologist sees a patient in the emergency department of the hospital for complaints of sudden onset severe lower epigastric tenderness. The patient also complains that he has seen signs of bleeding in his stools for the past few days. The patient also provides a history of chronic duodenal ulcers and previous gastrojejunostomy three years back after which he had had no signs and symptoms until now.

Upon examination, your clinician notes paleness of the sclera, skin and nails. He also notes epigastric tenderness, tachycardia and hypotension. He orders for lab tests to check bleeding time, CBC and LFT. He also performs an upper EGD and notices hemorrhage which he controls with the application of electrocautery. Based on signs and symptoms and observations of the EGD, your clinician arrives at a diagnosis of acute gastrojejunal ulcer with hemorrhage.

What to report: You report the evaluation of the patient using 99223 (Initial hospital care, per day, for the evaluation and management of a patient…). You should report the EGD procedure done to control the bleeding with 43255 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with control of bleeding, any method).

You report the diagnosis with 534.00 (Acute gastrojejunal ulcer with hemorrhage without obstruction) if you’re using ICD-9 codes and K28.0 if you’re using ICD-10 codes. 

Because the E&M service was done on the same date, you should be on the look-out for a denial from the carrier.  Some carriers are rather strict and consider all E&M services performed on the date of any procedure as included in the procedure fee.

If you get a denial, then you should appeal and append modifier -57 (Decision for surgery) to the E/M service for the evaluation a patient who, as a result of that evaluation, requires a procedure that will be performed the same day. This is the decision-making E/M.  The same modifier should be used on future claims to that carrier to avoid repeating the denial and appeal cycle.