Help! Gerd Esophagitis and Esophageal Spasms

[Jullang21]

Exam Training Packages
Hello everyone!

I need some advice.

Recently encounter a chart where a patient came in for an EGD w/biopsy. Physician document on operative report that "esophageal spasm" was noted, "possibly due to dysphagia." Dysphagia was the indication for the procedure. The path report revealed, reflux esophagitis. So the report was finally coded as Gerd w/esophagitis as the final diagnosis.

Question: Is it appropriate to code esophageal spasms as a secondary diagnosis on billing claim along with Gerd w/esophagitis? I personally believe that the esophageal spasm is trigger by the gerd reflux and is not significant to be coded since the pathologist stated findings as reflux esophagitis.

This is a debate with my management as they feel esophageal spasm is significant to the final diagnosis.

AAPC experts what do you think. Please provide your feedback so that I may share with my organization.

Thanks!

 

[dimmitta]

Gerd esophagitis and esophageal spasms

Question: Is it appropriate to code esophageal spasms as a secondary diagnosis on billing claim along with Gerd w/esophagitis? I personally believe that the esophageal spasm is trigger by the gerd reflux and is not significant to be coded since the pathologist stated findings as reflux esophagitis.

Personally, I would code both. Even though GERD can be a contributing factor for the presence of esophageal spasms, not every patient with GERD has spasms, so technically it would not be considered a symptom of GERD. Esophageal spasms can be caused by other unrelated issues such as medication, stress, anxiety, food temperature, etc. Since there are no Excludes 1 notes on either code saying not to code these together, I would use both codes since both were documented. Not sure if that helps, but that's my opinion...

 

[Jullang21]

After researching further I now have a better understanding and I agree with your comments. Thank you.