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Question: An established patient with Barrett’s esophagus came in for a surveillance visit. The gastroenterologist examined the patient and evaluated their symptoms. The physician then performed an endoscopy of the esophagus and performed a biopsy during the procedure. The sample was tested for dysplasia at an outside laboratory. The results confirmed high-grade dysplastic changes. The gastroenterologist diagnosed the patient with Barrett’s esophagus with high-grade dysplasia.

How should I report the diagnosis?

Vermont Subscriber

Answer: Use K22.711 (Barrett’s esophagus with high grade dysplasia) to report the documented diagnosis.

The K22.7- (Barrett’s esophagus) code subcategory in the ICD-10-CM code book is broken down into two further selections depending on the presence of dysplasia:

• K22.70 (Barrett’s esophagus without dysplasia)
• K22.71- (Barrett’s esophagus with dysplasia)

If the patient is experiencing Barrett’s esophagus with dysplasia, as in your situation, a 6^th character is required to identify the type of dysplasia confirmed:

• K22.710 (Barrett’s esophagus with low grade dysplasia)
• K22.711

Additionally, you’d use K22.719 (Barrett’s esophagus with dysplasia, unspecified) if there is not enough information in the documentation to identify whether the dysplasia is low grade or high grade.

Mike Shaughnessy, BA, CPC, Production Editor, AAPC