Should You Code GERD Separately From Barrett’s Esophagus?
Question: I have an esophagogastroduodenoscopy (EGD) report documenting Barrett’s esophagus without dysplasia and gastroesophageal reflux disease (GERD). Should I report both diagnoses or is GERD considered inherent to Barrett’s esophagus? New York Subscriber Answer: When the physician documents both Barrett’s esophagus and GERD, you generally should report both — when each condition meets the ICD-10-CM reporting requirements. Do not assume that GERD is inherent to Barrett’s esophagus simply because the two conditions often occur together. Assign K22.70 (Barrett’s esophagus without dysplasia) for Barrett’s esophagus without dysplasia. Meanwhile, you’ll use K21.9 (Gastro-esophageal reflux disease without esophagitis) for GERD without esophagitis. ICD-10-CM places these conditions in separate categories, and neither code carries an instruction that prevents you from reporting the other. The ICD-10-CM Official Guidelines for Coding and Reporting support reporting documented conditions that coexist at the time of the encounter and require or affect patient care, treatment, or management. The guidelines also state that chronic diseases treated on an ongoing basis may be reported each time the patient receives treatment or care for the conditions. Therefore, if the EGD documentation identifies both Barrett’s esophagus without dysplasia and GERD, and the physician manages or evaluates both conditions, you can report: The American College of Gastroenterology (ACG) also recognizes Barrett’s esophagus as a distinct clinical condition that requires specific diagnosis and surveillance. Its guideline recommends biopsy confirmation of intestinal metaplasia when diagnosing Barrett’s esophagus. Pay close attention to the documentation of esophagitis. If the physician documents GERD with esophagitis, you should not use K21.9. ICD-10-CM provides separate codes for GERD with esophagitis, including K21.00 (Gastro-esophageal reflux disease with esophagitis, without bleeding) and K21.01 (Gastro-esophageal reflux disease with esophagitis, with bleeding). You also should not infer a diagnosis that the physician did not document. For example, if the EGD identifies changes suggestive of Barrett’s esophagus but the physician has not established Barrett’s esophagus, review the pathology and physician documentation before assigning K22.70. Bottom line: Do not consider GERD automatically inherent to Barrett’s esophagus for coding purposes. When the physician documents both conditions and both meet the reporting requirements, report K22.70 for Barrett’s esophagus without dysplasia and the appropriate K21.- code for GERD. In this example, assuming the physician documents GERD without esophagitis, report K21.9. Suzanne Burmeister, BA, MPhil, Medical Writer and Editor
