Pathology/Lab Coding Alert

Question: The surgeon submitted a stomach biopsy of “inflamed tissue” from an esophagogastroduodenoscopy (EGD) procedure for a patient with gastroesophageal reflux. The pathologist diagnosed the biopsy as a gastric ulcer with H. pylori infection. What is the correct diagnosis — for GERD or stomach ulcer?

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Answer: You should code the final diagnosis when it is available at the time of billing. In this case, the pathologist diagnosed gastric ulcer and Helicobacter pylori infection.

Without further detail from the surgeon regarding a known ulcer or other symptoms, such as bleeding or perforation, you should code the ulcer as K25.9 (Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation).

Because the pathologist also indicated findings of H. pylori infection, you should also list B96.81 (Helicobacter pylori [H. pylori] as the cause of diseases classified elsewhere).

You should not code the gastroesophageal reflux disease (GERD) because that is not relevant to the pathology exam findings for the stomach biopsy.