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Wiki Esophageal BX

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chewri

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Could I please get help with DX coding the following Esophageal BX:
Ulcer with Herpes Virus inclusions.

Thanks:)
 
Hi. I code for a pathology group.

I would code 530.20 for the esophageal ulcer. I am always hesitant to code for herpes or any other specific infection unless I am sure a definitive diagnosis has been made. Is there anything specific in the microscopic or stains or cultures to give you the confidence to also code for herpes? If not, I would use just 530.20.
 
The original report said:
Squamous Epithelium showing focal areas of ulceration with atypia.... It was then sent to Upstate Medical University for Consultation and final report and the BX report That was in original thread was from the university.
I do greatly appreciate your help.
 
Considering "Herpes Virus inclusions" in the consultant's diagnosis, I wouldn't add the herpes code 054.79 unless I was convinced that your consultant or your pathologist had made a definitive diagnosis for herpes. It would be worth asking if they consider just the presence of the inclusions to be diagnostic for herpes or if the herpes diagnosis requires additional testing for confirmation.
 
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