General Surgery Coding Alert

Question: The surgeon submitted an esophageal biopsy taken during an esophagogastroduodenoscopy (EGD) with no mention of esophageal bleeding for a patient diagnosed with GERD. The pathology report noted “inflammation and reactive changes to the squamous mucosa.” What are the procedure and diagnosis codes for this case?

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Answer: You should code from the pathology report when the findings provide a definitive diagnosis. But in this case, the pathology findings are consistent with the presenting diagnosis of gastroesophageal reflux disease (GERD) and do not point to a separate diagnosis.

That means you should code the GERD as the diagnosis. Because the surgeon does not note bleeding during the EGD, you should code the case as K21.00 (Gastro-esophageal reflux disease with esophagitis, without bleeding).

Similar codes: 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 noted in the pathology exam as the diagnosis using a code such as K20.90 (Esophagitis, unspecified without bleeding). But that code has an Excludes1 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 or pathological findings, such as K22.1- (Ulcer of esophagus) or K22.7- (Barrett’s esophagus).

Procedure: You should code the surgeon’s procedure as 43239 (Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple).