Internal Medicine Coding Alert

Question: Has anyone come across chronic carditis on a biopsy taken from the gastroesophageal junction? When I look up the ICD-9-CM manual, I get pointed to heart disorders. What diagnosis code should I use?

Georgia Subscriber

Answer: Chronic inflammation at the gastroesophageal junction (carditis) appears to be a specific finding related to helicobacter pylori infection or chronic gastroesophageal reflux disease. If all your physician gave you was 'carditis,' it means an inflammation in the area of the GE junction is present. This may be an untraditional diagnosis word for reflux disease. In this case, you should code 530.81 (Esophageal reflux).

Quick fact: You should also code 530.81 if the gastroenterologist stated that the patient has NERD. NERD stands for nonerosive reflux disease. Essentially, it's gastroesophageal reflux disease (GERD), or heartburn, without damage to the mucous membrane. On the other hand, you should report GERD with damage to the esophagus with 530.11 (Esophagitis; reflux esophagitis).