Wiki Coding Grades of Esophagitis Question

[Cpg26b]

Coding Grades of Esophagitis Question

When a Diagnosis is listed as Grade “x” Esophagitis with no additional detail, what DX code(s) would you assign for each of the below grades?

-If there’s not one base code for each, would you code a base NOS or Other (K20.80/K20.90) and add erosion, ulcer, Barrett’s, etc.?
The Savary-Miller grading system commonly used:
Grade 1: single or multiple erosions on a single fold. Erosions may be exudative or erythematous.
Grade 2: multiple erosions affecting multiple folds. Erosions may be confluent.
Grade 3: multiple circumferential erosions.
Grade 4: ulcer, stenosis, or esophageal shortening.
Grade 5: Barrett's epithelium. Columnar metaplasia in the form of circular or non-circular (islands or tongues) extensions.

The more recent and more objective Los Angeles grades A to D classification is also used:
Grade A: one or more mucosal breaks no longer than 5 mm, none of which extends between the tops of the mucosal folds.
Grade B: one or more mucosal breaks more than 5 mm long, none of which extends between the tops of two mucosal folds.
Grade C: mucosal breaks that extend between the tops of two or more mucosal folds, but which involve <75% of the mucosal circumference.
Grade D: mucosal breaks which involve ≥75% of the mucosal circumference.

 

[thomas7331]

If the documentation only included a 'grade' and no more detail, I would simply use the NOS code K20.90. A grade is a severity and not a specified type of esophagitis, so I don't think K20.80 is correct. Standard coding guidelines generally don't allow for external or outside references such as these grading systems - you just have to stick with what the provider has documented in that patient's record. If you add specificity for a grade that isn't backed up in the medical record itself, I don't think it would hold up in an audit.

 

[Cpg26b]

Thank you!!