Gastroenterology Coding Alert

Question: We recently saw a 55-year-old established male patient with complaints of heartburn and severe upper abdominal pain. The physician performed an E/M service and several tests (including endoscopy) and confirmed a diagnosis of dyspepsia. How should we report functional dyspepsia?

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Answer: In most cases, a diagnosis of functional dyspepsia has to be reported with K30 (Functional dyspepsia).

Red flag: Be sure that the physician has specifically mentioned the term “functional,” since your question suggests that the doctor merely confirmed a “dyspepsia” diagnosis. If the actual diagnosis is dyspepsia, you’ll have to report R10.13 (Epigastric pain), which is what ICD-10 directs you to use for “dyspepsia NOS.”

Documentation spotlight: Some symptoms that you are most likely to encounter in the documentation of a patient suffering from functional dyspepsia might include upper abdominal pain; bloating; heartburn; belching; feeling of fullness; and nausea. Your clinician will record a complete history including history of any medications that the patient is currently taking and check for other symptoms such as vomiting, signs of bleeding (dark stools) or other GI symptoms to look for any other cause for the dyspepsia. Upon examination, your clinician might note signs of tenderness on palpating the upper abdominal area.

However, you cannot report K30 unless your physician has definitely diagnosed the patient with functional dyspepsia, even if the above symptoms are mentioned in the report.