Gastroenterology Coding Alert

Question: A patient presents with sharp stomach pain. The gastroenterologist performs an endoscopy and diagnoses a duodenal ulcer. The notes are sparse, and there isn’t even mention of whether this condition is acute or chronic. The physician says he’s unable to provide additional information. Which code should I use?

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Answer: Ideally, the physician will have been able to determine chronic versus acute and whether there’s an obstruction, hemorrhage, or perforation. However, you’ve already queried the provider, which was the logical first step. Here are a few options to consider.

Without knowing exactly how sparse the notes are, it’s hard to point to an exact code. However, you don’t need to know whether the ulcer is chronic or acute to use codes from K26.4-K26.6 (Chronic or unspecified duodenal ulcer …). You do need to know a few things though, as these codes describe the presence of hemorrhage, perforation, or both. If neither hemorrhage or perforation is present, and the physician has not and cannot provide information on any of those details, your only option is to report K26.9 (Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation).