General Surgery Coding Alert

Question: I’m coding an op report for an EGD to treat esophageal varices (I85.00). But the medical record indicates that the patient has alcoholic cirrhosis without ascites with esophageal varices. Should I update the diagnosis in the claim to K70.30?

Utah Subscriber

Answer: You shouldn’t change a diagnosis for a claim without checking with the surgeon. But your role as a coder is to report the most accurate code(s) for a service, so if you think an amendment to the report is warranted, contact the provider.

According to the 2022 ICD-10-CM Official Guidelines for Coding and Reporting, “a joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures … The importance of consistent, complete documentation in the medical record cannot be overemphasized. Without such documentation accurate coding cannot be achieved. The entire record should be reviewed to determine the specific reason for the encounter and the conditions treated.”

So if you’ve reviewed the entire record to pinpoint the most accurate diagnosis code, you are following the guidelines as they were intended. It’s reasonable to approach the provider and ask whether the more accurate coding sequence would be K70.30 (Alcoholic cirrhosis of liver without ascites) and I85.10 (Secondary esophageal varices without bleeding), and if so, if the provider would be willing to amend the medical record to note that these are the more accurate.