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EGD with biopsy

  1. Question EGD with biopsy
    Medical Coding Books
    My doctor performed and EGD with biopsy. His report states "segmental continuous granularity, friability and erythema of the mucosa with no bleeding was noted in the antrum. These findings are compatible with gastritis. Cold forceps biopsies were performed". The pathology report comes back with a diagnosis of "Unremarkable antral-type mucosa". Because the doctor states finding were compatible with gastritis, could I use the unspecified gastritis code (535.50) or do I code the indication for the procedure, which was epigastric pain (789.06)? Thanks for you help!!

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    I would use epigastric pain since the path didn't specify gastritis. A doctor may think something 'looks like' a diagnosis (a surgeon may say a lesion is "suspicious for cancer" but turns out to be benign pathology)- but until the path proves it, I don't use it. Anyone else have thoughts about this?

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    What I'm getting hung up on is his use of the terminology "compatible with", as opposed to "suggestive of" or "suspicious for". I've been taught this is a more definitive useage and could be used to diagnosis if there is no other specific diagnosis?

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    I still don't trust the 'compatible with' as a definitive diagnosis. Unless the pathology comes back as gastritis, I wouldn't code the gastritis. The only thing for certain, if the path comes back as normal tissue, is the symptom - epigastric pain. But I learned that many years ago - doesn't mean things haven't you have documentation that states "compatible with" observations can be used as coded diagnoses?

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