Gastroenterology Coding Alert

Hint: Use same basis for arrival at final code as in ICD-9.

When your gastroenterologist diagnoses acute gastritis, you’ll have to scour through patient documentation to check presence or absence of bleeding to arrive at the appropriate diagnosis code while reporting the condition with ICD-10 codes .

ICD-9: You have two code choices to choose from depending on the presence or absence of bleeding or hemorrhage. Report the condition using one of the following two code choices:

• 535.00 — Acute gastritis [without hemorrhage]
• 535.01 — Acute gastritis with hemorrhage

Rely on Bleeding To Choose Appropriate ICD-10 Code

When you begin using ICD-10 codes after Oct.1, 2014, you’ll report a diagnosis of acute gastritis with K29.0 (Acute gastritis). Using the same basis as under the ICD-9 system, you’ll note that K29.0 expands into two code choices depending on the presence or absence of bleeding. You can report a diagnosis of acute gastritis with these two codes in ICD-10:

• K29.00 — Acute gastritis without bleeding
• K29.01 — Acute gastritis with bleeding

Even though there is a slight descriptor change from ICD-9 to the corresponding ICD-10 codes for acute gastritis, there is not much change to the meaning, as the terms “hemorrhage” and “bleeding” are used synonymously.

Note: You cannot report a diagnosis of eosinophilic gastritis with the above mentioned code choices. You’ll have to report this using K52.81. Also, a diagnosis of Zollinger-Ellison syndrome should not be reported using K29.0. It should be reported with E16.4.

Heed These Basics

Documentation spotlight: When your gastroenterologist diagnoses acute gastritis, some of the signs and symptoms that you are more likely to see in patient documentation will include acute pain in the abdominal area, nausea, vomiting, reduced appetite, bloating, fever, chills, and belching. The pain in the abdominal area might reduce or, in some cases, increase with the intake of food.

During a physical examination, your gastroenterologist might note mild to moderate tenderness in the epigastric area. If your gastroenterologist suspects a diagnosis of acute gastritis, he might ask for lab studies such as stool tests, CBC, liver and kidney function tests and tests to check the functions of the gallbladder and the pancreas. Your gastroenterologist might also ask for imaging studies such as an x-ray to check for radiological signs to confirm a diagnosis of acute gastritis.

Apart from this, your gastroenterologist might also perform an endoscopy to observe the gastric folds to see signs of edema, bleeding and inflammation. During the procedure, your gastroenterologist might also take biopsy specimens to be sent for histological studies. These procedures along with histological test results will help your gastroenterologist arrive at the diagnosis of acute gastritis.

Example: Your gastroenterologist recently reviewed a 68-year-old male patient with complaints of developing severe epigastric tenderness coupled with nausea and bouts of vomiting over the period of three days. Upon questioning, the patient provides a history of use of NSAIDs for a very long period to help him control the severe pain in the joints that he has been having for over a decade now. The patient says that the pain disappears when he has his meals but return shortly thereafter.

Upon examination, your gastroenterologist notes epigastric tenderness. Suspecting acute gastritis, your gastroenterologist orders a stool test to check for occult blood and also orders CBC, liver function and kidney function tests along with tests for pancreatic function and gallbladder function. Your gastroenterologist also orders for an x-ray that shows areas of gastric erosions with edema in the area of the greater curvature of the stomach. The stool sample tests positive for occult blood.

Your gastroenterologist also performs an upper EGD to check the gastric folds and makes observation that the folds appear to be thickened and edematous with the presence of erosion and inflammation. During the endoscopy, your gastroenterologist also obtains biopsy samples that are sent to the lab for histological studies.

What to report: You’ll report the initial office visit with 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components…); the fecal occult blood test with 82274 (Blood, occult, by fecal hemoglobin determination by immunoassay, qualitative, feces, 1-3 simultaneous determinations). You’ll have to report the endoscopy that your gastroenterologist performed with 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple).

You will report the diagnosis of acute gastritis with K29.01 if you’re using ICD-10 codes and 535.01 if you are using ICD-9 coding system. You are using these code choices as the stool sample tested positive for occult blood.