Gastroenterology Coding Alert

Question: My gastroenterologist performed an EGD (43235) on a Medicare patient with severe anemia. Because no ICD-9 code exists for severe anemia, we reported 285.9 (Anemia, unspecified). Our Medicare carrier denied the claim because 285.9 is not "medically necessary." The gastroenterologist found mild gastritis but did not indicate that it was a reason for the severe anemia. Which diagnosis code should we have used?

Kansas Subscriber

Answer: Careful. You should never report diagnoses simply to be paid. You should report what your documentation specifies.

However, when your gastroenterologist lists a diagnosis for which there is no ICD-9 code, you should ask him to further clarify the diagnosis instead of giving it the default label of "unspecified."
Most carriers do not recognize unspecified anemia as a covered indication for an EGD, but your gastroenterologist may have been able to provide a more specific diagnosis, such as iron deficiency anemia (280.0-280.9) or acute posthemorrhagic anemia (285.1), which are usually covered diagnoses.
If you had better documentation, you could have also reported the gastritis (535.0-535.6). This is another commonly accepted indication for an EGD. The gastritis is an independent indication for the procedure and does not have to be the cause of the anemia for you to list it as the primary diagnosis. Because there is no ICD-9 code for "mild" gastritis, however, you would again have to ask your gastroenterologist to clarify the diagnosis.
The best way to find out which diagnoses your carrier accepts for EGDs or any other procedure is to check the carrier's local medical review policy (LMRP), which should be available on the carrier's Web site. The LMRP will contain a list of ICD-9 codes that support the medical necessity of the procedure.

Note: Experts recommend that you check LMRPs once a month.