Pathology/Lab Coding Alert

Question: The pathologist examined a duodenum biopsy from an esophagogastroduodenoscopy (EGD). The pathology report identified serosal fibrosis and granulation tissue with inflammatory cells and surface neutrophils. An H. Pylori test was positive. The final diagnosis is peptic ulcer. How should we code this?

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Answer: Report the pathologist’s biopsy exam using 88305 (Level IV - Surgical pathology, gross and microscopic examination … Stomach, biopsy …). For the Helicobacter pylori test on the biopsy specimen, labs typically perform a “campylobacter like organism” (CLO) test, which you can report using 87081 (Culture, presumptive, pathogenic organisms, screening only). 

You need to select the code for a peptic ulcer, based on site, which is the duodenum in this case. You’ll also need to ascertain from the medical record several details about the case. For instance, you should identify whether the ulcer is chronic or acute, and whether an obstruction, hemorrhage, or perforation was present.

Notice that you must list a code from the K26 (Duodenal ulcer) category with a 4th character, and that’s where the details come in. If the condition is acute, you’ll look to the K26.0-K26.3 codes (Acute duodenal ulcer …), which ICD-10-CM breaks down further based on whether the acute duodenal ulcer involved hemorrhage, perforation, both, or neither.

If you find that the patient suffers from chronic duodenal ulcers or you don’t have any indication of whether the condition was acute or chronic, you’ll instead need to look to the K26.4-K26.7 (Chronic or unspecified duodenal ulcer …) series. These codes also differ depending on the presence of hemorrhage, perforation, neither, or both.

Vague: If the medical record lacks information about whether the ulcer was acute or chronic in nature, your only remaining option is K26.9 (Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation). This code is less specific and should be your last resort failing more detailed information in the medical record.