General Surgery Coding Alert

Question: We have an op note that states “patient presents with sharp stomach pain.” The surgeon performed an endoscopy and diagnosed a “duodenal ulcer.” The notes are sparse with no mention of whether the condition is acute or chronic. There’s no evidence of a biopsy with an H. pylori test for the ulcer diagnosis. The surgeon says he’s unable to provide additional information. How should we code the diagnosis?

Texas Subscriber

Answer: You were correct to query the surgeon regarding details of the case. Accurately coding an ulcer would require knowing whether the condition is chronic or acute, and whether there is a hemorrhage or a perforation.

Best bet: You may report the diagnosis as K26.9 (Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation). Although you don’t have specific documentation that the patient does not have hemorrhage or perforation, this is your best choice. The other K26.- codes distinguish chronic or acute, or state affirmatively “with” hemorrhage or perforation, which is absent in the documentation.