Gastroenterology Coding Alert

Question: The surgeon took a tissue sample from the esophagus during an esophagogastroduodenoscopy (EGD) for a patient diagnosed with gastroesophageal reflux disease (GERD), but there was no evidence of any bleeding in the esophagus. The pathology report noted “inflammation and reactive changes to the squamous mucosa.” What are the appropriate procedure and diagnosis codes for this case?

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Answer: The pathology report confirms the presenting diagnosis of GERD, and there is no evidence of any separate or distinct diagnosis based on the findings. That means you should code GERD as the diagnosis. Because the surgeon does not note bleeding during the EGD, you should code the case as K21.00 (Gastro-esophageal reflux disease with esophagitis, without bleeding).

Take Note: Be sure you don’t mix up the code with other similar options in ICD-10-CM. For example, you might be inclined to use a code that represents the esophageal inflammation mentioned in the pathology exam as the diagnosis, such as K20.90 (Esophagitis, unspecified without bleeding). But that code has an Excludes1 note that eliminates using K20.- for esophagitis with GERD when GERD is the confirmed diagnosis. You should also avoid reporting common EGD findings that are not in evidence in the op report or pathological findings, such as K22.1- (Ulcer of esophagus) or K22.7- (Barrett’s esophagus).

“Whenever possible, the practice should wait to bill until the pathology report is available for an after-study diagnosis. Any additional information gained from the pathology report diagnosis is the most accurate information to report with the service, as well as sometimes affecting the correct CPT^® code,” says Terri Brame Joy, MBA, CPC, COC, CGSC, CPC-I, product manager, MRO, in Philadelphia.

Procedure: You should code the surgeon’s procedure as 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple).