Pathology/Lab Coding Alert

Question: The pathologist examined 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?

Florida Subscriber

Answer: The pathology report includes findings consistent with the presenting diagnosis of gastroesophageal reflux disease (GERD). That means the appropriate diagnosis is 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 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 pathologist’s esophagus biopsy exam as 88305 (Level IV - Surgical pathology, gross and microscopic examination … Esophagus, biopsy …).