Gastroenterology Coding Alert

Question: Our physician recently performed an EGD with banding of the varices. The indication on the procedure report states, “esophageal varices,” which is coded as I85.00. However, the report documents portal hypertension, which I know is associated with cirrhosis. The patient is established with our practice, so I looked back at prior records and verified that the patient does have alcoholic cirrhosis without ascites with esophageal varices, which is coded as K70.30 and I85.10. I believe the physician should update the report to the specified diagnosis, so the claim has the correct diagnosis for this patient (K70.30 with I85.10). However, my co-worker thinks I should not look at previous records. She says I should just code directly from the procedure report and use I85.00 as the diagnosis. Please advise how this situation should be resolved.

Idaho Subscriber

Answer: Your role as the coder is to use your coding knowledge (and not just what’s written on the superbill) to find the most accurate code(s) for a service, so in some cases, it would be appropriate to ask the provider whether an amendment to a report is warranted. You shouldn’t simply code a service as the physician suggests if you believe additional diagnosis codes are required — but on the other side of the coin, you should never add diagnoses without first speaking to the provider.

According to the 2022 ICD-10-CM Official Guidelines for Coding and Reporting, “a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures … The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”

So if you’ve reviewed the entire record to pinpoint the most accurate diagnosis code, you are following the guidelines as they were intended. It’s reasonable to approach the provider and ask whether the more accurate coding sequence would be K70.30 (Alcoholic cirrhosis of liver without ascites) and I85.10 (Secondary esophageal varices without bleeding), and if so, if the provider would be willing to amend the medical record to note that these are the more accurate diagnoses to report.