Gastroenterology Coding Alert

Question: A new patient to our practice presented with a complaint of heartburn. The provider performed an E/M visit and identified that it was a recurrent problem interfering with the patient’s daily routine. He performed an examination as well. The GI physician then assigned a confirmed diagnosis of GERD and started the patient on GERD medication to relieve the symptoms. Which diagnosis 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 in the absence of esophagitis, you will need to assign 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 you only report these 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)
• R07.9 (Chest pain, unspecified)

Don’t forget: Remember to report appropriate diagnosis codes with a new patient E/M code from 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) 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.