General Surgery Coding Alert

Question: The surgeon performed an EGD with biopsy for a patient with burning, sharp pain in the upper abdomen. When coding the case after receiving the pathology report and the final diagnosis of a duodenal ulcer, what is the appropriate diagnosis code(s)?

Iowa Subscriber

Answer: To select the correct code for a duodenal ulcer, you need to ascertain from the medical record several details about the case. For instance, you should identify whether the ulcer is chronic or acute, and whether an obstruction, hemorrhage, or perforation was present.

Notice that you must list a code from the K26 (Duodenal ulcer) category with a 4th character, and that’s where the details come in. If the condition is acute, you’ll look to the K26.0-K26.3 codes (Acute duodenal ulcer …), which ICD-10-CM breaks down further based on whether the acute duodenal ulcer involved hemorrhage, perforation, both, or neither.

If you find that the patient suffers from chronic duodenal ulcers or you don’t have any indication of whether the condition was acute or chronic, you’ll instead need to look to the K26.4-K26.7 (Chronic or unspecified duodenal ulcer…) series. These codes also expand further depending on the presence of hemorrhage, perforation, neither, or both.

Vague: If the medical record lacks information about whether the ulcer was acute or chronic in nature, your only remaining option is K26.9 (Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation). This code is less specific and should be your last resort failing more detailed information in the medical record.