Primary Care Coding Alert

Question: Should I code for corrected gastroschisis when the patient comes in complaining of stomach pain?

Washington Subscriber

Answer: Whether you report Z87.761 (Personal history of (corrected) gastroschisis) depends on whether the physician connected the gastroschisis with the presenting problem. Many congenital conditions can recur and, therefore, may require continued monitoring, which means personal history codes can absolutely help round out a patient record. However, before you report them, you should, make sure the physician has first clearly connected the current symptoms with the congenital condition. Then, you’ll need to make sure the physician has adequately documented them, having spent time or expertise evaluating it.

This rationale is evident in ICD-10 Official Guideline I.C.17, which says, in part, “Codes from Chapter 17 [Congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99)] may be used throughout the life of the patient. If a congenital malformation or deformity has been corrected, a personal history code should be used to identify the history of the malformation or deformity.”

Notice also that guideline I.C.17 says the chapter 17 code may be used, but that doesn’t mean it must be used. Gastroschisis (Q79.3) is a birth defect that causes an opening in the skin and muscles that cover the abdominal wall, allowing intestines and sometimes other organs to bulge outside the body. This is corrected with one and, sometimes, two surgeries. It’s possible that as these patients get a little older, they may start having trouble absorbing nutrients or might suffer from acid reflux. It’s up to the physician to make that determination and indicate a connection when they document the encounter.