Gastroenterology Coding Alert

Question: The gastroenterologist suspected Barrett’s esophagus, which prompted an upper GI. Ultimately, the physician found a gastric ulcer that they attribute to the patient’s long-term use of ibuprofen. They do not confirm Barrett’s esophagus, but it’s still in the notes. Do I code it?

Oregon Subscriber

Answer: In this situation, report the primary diagnosis, which is a gastric ulcer, but do not report Barrett’s esophagus. Here’s why.

Physicians typically perform upper GI services to diagnose conditions after patients complain of symptoms. If the gastroenterologist has a diagnosis in mind, it is worth noting in the patient record from a clinical perspective. Thorough notes are important so that all the prior thought-processes can be documented for future use. They are helpful for that same physician or others to know which ailments have been considered, which ones have been ruled out, and which ones are still under consideration. These kinds of notes also potentially aid in medical decision making (MDM) and leveling E/M visits. Physicians get credit for the work they do, which includes ruling out potential problems.

However, don’t report suspected or discarded diagnoses on claims. Once an official diagnosis is established, that’s the time to report a diagnosis code. In this case, you’d use a code such as K25.9 (Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation). Additionally, you’ll want to include Z79.1 (Long-term [current] use of non-steroidal anti-inflammatories [NSAID]) as your secondary diagnosis to account for the long-term use of ibuprofen. Since Barrett’s esophagus (K22.7-, Barrett’s esophagus) was ruled out, you should not report that code.