Gastroenterology Coding Alert

Question: What diagnosis should I use for gastrointestinal endoscopies (EGD, 43235) performed on a patient to re-evaluate a previous gastric ulcer? The preoperative diagnosis in the patient's medical record reads, "History of gastric ulcer" and the ulcer is now healed. Should I use 531.90 or V12.71?

Texas Subscriber

Answer: The diagnosis code you use to report the EGD will explain the specific reason why the gastroenterologist thought it was necessary to perform the endoscopy. From your question, the reason is unclear.
While your scenario appears to be a follow-up EGD, whether the gastroenterologist knew the ulcer was healed before he performed the endoscopy is unclear. If your gastroenterologist performed the endoscopy to determine whether the ulcer was healed, use 531.90 (Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation; without mention of obstruction).

If the gastroenterologist knew the old ulcer was healed before he performed the EGD, use V12.71 (Personal history of peptic ulcer disease). Many payers will not reimburse for the procedure if the V code is the only diagnosis code you report.

When the V code is used, coders should check if the patient was presenting with other signs or symptoms, such as epigastric pain (789.06). In this case, you should use those signs or symptoms as the primary diagnosis. Then, you would report the V code as a secondary diagnosis.