General Surgery Coding Alert

Question: The surgeon performed an endoscopy with esophagus biopsy for a patient with a diagnosis of Barrett’s esophagus. The pathology report documented low-grade dysplastic changes. How should we code the case?

Iowa Subscriber

Answer: You don’t really provide enough information to assign a definitive procedure code, such as the approach, or whether the scope was flexible or rigid. Based on those details, you would select an appropriate procedure code such as 43202 (Esophagoscopy, flexible, transoral; with biopsy, single or multiple).

Regarding the diagnosis, you’re wise to wait for the pathology report to assign the correct code. Just be aware that the latest version of ICD-10-CM that is effective Oct. 1 makes some big changes to coding for Barrett’s esophagus.

K22.71 (Barrett’s esophagus with dysplasia) will get you in the right zone, but that’s not a complete code, so you need to look further. K22.71 expands to the sixth digit in ICD-10-CM 2019, so you’ll need to use that pathology-report documentation to choose the correct code. In this case, you should report K22.710 (Barrett’s esophagus with low grade dysplasia).

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