Gastroenterology Coding Alert

Question: A new patient presented with a complaint of heartburn. The provider took a problem-focused history and identified that it was a recurrent problem interfering with the patient's daily routine. He performed an examination as well. Satisfied with the history and symptoms of the patient, the provider assigned a confirmed diagnosis of GERD and started the patient on GERD medication to relieve the symptoms. Which diagnoses codes should we report for the final diagnosis, as well as the signs and symptoms, and which procedure code should we submit?

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Answer: If your provider identifies GERD, you will need to assign one of the two ICD-10 codes for GERD. In this scenario, as the provider confirms a diagnosis of GERD, we would code it as K21.9 (Gastro-esophageal reflux disease without esophagitis). You may want to be sure about whether the patient has esophagitis or not, before assigning this code. Don't worry about sending a query to your provider yet. You can code K21.9 as a default code for GERD as it includes esophageal reflux NOS.

Signs and symptoms: As for coding signs and symptoms, remember these are only to be coded when there is no definitive diagnosis. If patient has heartburn and indigestion but GERD has not been specifically diagnosed, then the signs and symptoms would be coded. For example:

• R12 (Heartburn)
• R05 (Cough)
• K30 (Functional dyspepsia)
• R06.2 (Wheezing)
• J37.0 (Chronic laryngitis)
• J37.1 (Chronic laryngotracheitis).

Don't forget: Remember to report appropriate diagnosis codes with an E/M code from 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; Straightforward medical decision making....) for reporting the encounter.

Important: These symptoms can sometimes also be caused by cardiac or pulmonary problems, so make it a point to report any pre-existing chronic conditions and habits that may exacerbate GERD such as asthma (J45.-), obesity (E66.-), smoking, pregnancy and hereditary predisposition.