General Surgery Coding Alert

Reader Questions:

File Final Dx Code Instead of Symptoms

Published on Fri May 20, 2022

Question: Our surgeon performed an EGD for a patient complaining of recurrent heartburn, cough, and laryngitis. During the procedure the surgeon identified inflammatory changes in the esophagus and diagnosed the patient with GERD. What diagnosis code(s) should we use for the case?

Alabama Subscriber

Answer: You should code the final diagnosis, not the presenting signs and symptoms. Because the surgeon doesn’t mention esophageal bleeding, you’ll code the case “without bleeding.”

The appropriate code is K21.00 (Gastro-esophageal reflux disease with esophagitis, without bleeding).

Similar: You need to ensure that you don’t confuse the code with similar ICD-10-CM options. For instance, you might be tempted to report the esophageal inflammation as the diagnosis using a code such as K20.90 (Esophagitis, unspecified without bleeding). But that code has an Excludes 1 note that eliminates using K20.- for esophagitis with gastro-esophageal reflux disease. You should also avoid reporting common Esophagogastroduodenoscopy (EGD) findings that are not in evidence in the op report, such as K22.1- (Ulcer of esophagus) or K22.7- (Barrett’s esophagus)

Symptoms: Because the surgeon reports a final diagnosis based on the patient’s clinical symptoms and EGD findings, you should not report the following symptoms when you file the claim: