Pathology/Lab Coding Alert

Question: The pathologist examined two distinct specimens from an EGD procedure for a patient diagnosed with GERD. With no reported esophageal bleeding, the biopsies were taken 6 cm (Specimen A) and 1.5 cm (Specimen B) proximal to the GE junction. The pathologist noted reactive squamous mucosa changes and inflammation in Specimen A, and noted “metaplastic epithelium” in Specimen B. How should we code this?

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Answer: For the procedure, report two units of 88305 (Level IV - Surgical pathology, gross and microscopic examination… Esophagus, biopsy…). Because the surgeon separately submits two distinct specimens from the esophagogastroduodenoscopy (EGD) surgery and the pathologist separately diagnoses the two specimens, you should bill 88305 x 2.

Dx Specimen B: The presence of goblet cells (intestinal metaplasia) more than 1 cm proximal to the gastroesophageal (GE) junction indicates a diagnosis of Barrett’s Esophagus (BE).

Here’s why: The esophageal lining (mucosa) is typically comprised of flat, squamous cells, while the intestine is lined with columnar (column-shaped) cells called goblet cells, which secrete mucous to protect the lining in the face of digestive acids. When a patient has gastroesophageal reflux disease (GERD), which creates repeated acid exposure to the esophagus, goblet cells may begin to replace normal squamous cells (called intestinal metaplasia).

Report the diagnosis of the biopsy exhibiting intestinal metaplasia greater than 1 cm proximal to the GE junction as K22.70 (Barrett’s esophagus without dysplasia), because the pathology report does not identify dysplasia.

Dx Specimen A: Because the patient has a firm diagnosis of GERD, the appropriate diagnosis code for this biopsy is K21.00 (Gastro-esophageal reflux disease with esophagitis, without bleeding). You should not code the esophageal inflammation noted on the pathology report as K20.90 (Esophagitis, unspecified without bleeding) because the case involves inflammation associated with GERD, which is not ‘unspecified.”