You Be the Coder:
Anemia,Gastritis as Indicators for EGD
Published on Sat Jun 01, 2002
Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.
Question: An EGD (43235) was performed 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 told us that 285.9 is not "medically necessary" and denied the claim.
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?
Maryland Subscriber
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Answer: When your gastroenterologist lists a diagnosis for which there is no ICD-9 code, you should ask him or her to further clarify the diagnosis instead of giving it the default label of "unspecified," according to Michael L. Weinstein, MD, a gastroen-terologist in Washington, D.C., and a former member of the CPT advisory panel.
Most carriers do not recognize unspecified anemia as a covered indication for an EGD, but your gastroen-terologist 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.
You could have also reported the gastritis (535.0-535.6) because it 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 to be listed as the primary diagnosis. Because there is no ICD-9 code for "mild" gastritis, however, you would again have to ask your gastroen-terologist to clarify on 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 to you on the carrier's Web site. The LMRP will contain a list of ICD-9 codes that will support the medical necessity of the procedure.
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