Gastroenterology Coding Alert

Question: One of our providers recently saw a teenaged patient who was complaining of stomach pain. The patient’s record shows he had gastroschisis as an infant, which was corrected. The doctor did not highlight this detail in the notes from the most recent encounter. ICD-10 Official Guideline I.C.17 says, “Codes from Chapter 17 [Congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)] may be used throughout the life of the patient. If a congenital malformation or deformity has been corrected, a personal history code should be used to identify the history of the malformation or deformity.” Should I therefore code the corrected condition?

Ohio Subscriber

Answer: No, there is no need to report Z87.761 (Personal history of (corrected) gastroschisis) in this instance. Here’s why.

Gastroschisis is a birth defect that causes an opening in the skin and muscles that cover the abdominal wall, allowing intestines and sometimes other organs to bulge outside the body. This is corrected with one, and sometimes two, surgeries. It’s possible that these young patients have trouble absorbing nutrients throughout childhood or might suffer from acid reflux. However, since the physician did not connect the corrected condition with that day’s stomach pain, you wouldn’t report it.

The guideline you reference says that the congenital malformation codes may be used throughout the life of the patient. It doesn’t say that they must be used, though. Personal history codes absolutely help round out a patient record, and many congenital conditions can recur and, therefore, may require continued monitoring.

However, not only did the physician not connect the stomach pain with the congenital condition, they also did not make note of having spent time or expertise evaluating it.