retained foodstuffs distal esophagus and proximal stomach

KBean2018

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Hello, I cant seem to find the right dx for retained foodstuffs distal esophagus and proximal stomach. I was looking at T18.120A-Food in esophagus causing compression of trachea, initial encounter. Any help appreciated. thank you
 

RyanRaichCPC

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Is the compression of the Trachea actually documented? If not, then you may need to select a less specific ICD 10 code or query your provider. If you post a snippet from your docs documentation, I would be happy to try to help you find a code for this.
 

KBean2018

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Thank you so much for your assistance. No the compression of trachea was not documented.

PRE-OP DIAGNOSIS: retained proximal gastric fundus

POST-OP DIAGNOSIS: Same, retained foodstuffs distal esophagus and proximal stomach

PROCEDURE: Intraoperative diagnostic EGD

PROCEDURE: In the operating room she is under general anesthetic and the lubricated gastroscope was introduced behind the tongue finding the endotracheal tube anteriorly and arytenoid cartilage posteriorly, the scope is advanced posterolaterally into the cricopharyngeal inlet into the esophagus and stomach. Stomach is unremarkable although narrowed as a tube, slowly withdrawn and on the left lateral and posterior lateral aspect the retained fundus is identified. This has a length of about 5 cm and as the scope was withdrawn we visualize Z line without significant elevation, and anatomically with laparoscope, recognize externally at the esophagogastric junction. Dr. completes release of the esophageal hiatus and its closure, dictated separately. The scope was left in place with the light off, and then when appropriate, illuminated again and monitored so that the redundant fundus could be amputated from the intra-abdominal side, dictated separately. At conclusion the stomach is deflated, no narrowing at the esophagogastric junction or proximal stomach, nor bleeding and the scope was withdrawn.
 

RyanRaichCPC

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Local Chapter Officer
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Lawrence, KS
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In this case, I would query your provider as you have pretty limited options on your ICD10. Per the ICD-10 book, the code you selected T18.120A seems the best option to me as well, however, we cannot assume that the Trachea was compressed. T18.120A can also be used if the patient's respiration was affected by the retained food. I am sorry that I cannot be more help on this one! If there was some other 'injury' caused by the retained food, you could use the less specific code under T18.12 Sorry I wasn't too much help KBean!
 
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