Gastroenterology Coding Alert

Hint: You cannot report K30 for psychogenic dyspepsia.

When reporting a diagnosis of functional dyspepsia, you’ll have a very specific code in ICD-10 for this condition, whereas, in ICD-9, you’re limited to a more generic code that covers all functional disorders of the stomach.

ICD-9: You report a diagnosis of functional dyspepsia using the ICD-9 code 536.8 (Dyspepsia and other specified disorders of function of stomach). You’ll use the same diagnosis code for other diagnoses such as achyliagastrica; hourglass contraction of stomach; hyperacidity; hyperchlorhydria; hypochlorhydria; indigestion; or tachygastria. However, you cannot use 536.8 if the diagnosis is achlorhydria (536.0); heartburn (787.1) or for functional disorders of the stomach specified as psychogenic (306.4).

ICD-10: When you begin using ICD-10 codes, a diagnosis of functional dyspepsia has to be reported with K30 (Functional dyspepsia). Unlike in ICD-9, you have a very specific code in ICD-10 to report functional dyspepsia and you do not use the same diagnosis code for other conditions as you do with 536.8 in ICD-9.

Red flag: However, you cannot use K30 when your clinician is assessing symptoms of dyspepsia caused due to another condition. In such a case, you report this with R10.13. You also cannot use K30 when the symptom is of heartburn (R12). In addition, the other diagnoses that your clinician makes for which you cannot report K30 includes nervous dyspepsia; neurotic dyspepsia or psychogenic dyspepsia. You report all these conditions using F45.8 (Other somatoform disorders).

Check These Basics Briefly

Documentation spotlight:Some symptoms that you are most likely to encounter in the documentation of a patient suffering from functional dyspepsia might include upper abdominal pain; bloating; heartburn; belching; feeling of fullness; and nausea. Your clinician will record a complete history including history of any medications that the patient is currently taking and check for other symptoms such as vomiting, signs of bleeding (dark stools) or other GI symptoms to look for any other cause for the dyspepsia. Upon examination, your clinician might note signs of tenderness on palpating the upper abdominal area.

Tests: Since the signs and symptoms of functional dyspepsia will mimic other conditions such as an ulcer, gastroesophageal reflux disease (GERD); dyspepsia caused as a result of medications and other serious conditions such as cancer, your gastroenterologist will want to rule out these conditions prior to arriving at a diagnosis of functional dyspepsia.

Your clinician will undertake an upper GI endoscopy to see if there is a cause for the dyspepsia and to rule out any serious complications such as an ulcer that is bleeding or has caused a perforation. As H. pylori infections are also thought of to be a cause for causing the symptoms of functional dyspepsia, your clinician might also order for tests to check for H. pylori infections.

Based on the history, symptoms, and tests to rule out other causes of the symptoms of dyspepsia, your clinician will arrive at the diagnosis of functional dyspepsia.

Example: Your gastroenterologist recently reviewed a 55-year-old established male patient with complaints of heartburn and severe upper abdominal pain. He says that he has had these symptoms for sometime now and the trouble has been gradually on the rise. He says that intake of food has not much influence on reducing his symptoms although it sometimes helps.

Your gastroenterologist recorded a complete history of the patientincluding a review of allergies and past, family, and social history. The patient’s current medication list was updated. He also has no history of any vomiting or blood in the stools. Upon examination, the patient experienced tenderness on palpation of the upper abdominal area.

Your gastroenterologist also ordered for a C-13 breath test to check for H. pylori infection. The test returned negative for presence of H. pylori infection.

Your gastroenterologist subsequently performed an upper abdominal endoscopy to see if the patient has any problems such as an ulcer, strictures, signs of reflux, and to check for any other lesions or masses that could be causing the problem. He notes that he found no such signs of significance.

Based on history, signs and symptoms, and results of tests, your gastroenterologist confirmed a diagnosis of functional dyspepsia.

What to report: You report the evaluation of the patient using 99213 (Office or other outpatient visit for the evaluation and management of an established patient…); the EGD procedure with 43235 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]).

You report the C-13 breath test using 83013 (Helicobacter pylori; breath test analysis for urease activity, non-radioactive isotope [e.g., C-13]) for the analysis that your gastroenterologist provides and use 83014 (Helicobacter pylori; drug administration) for the administration of the non-radioactive isotope.

You report the diagnosis with K30 if you’re using ICD-10 codes or use 536.8 if you are using ICD-9 coding system.