Gastroesophageal Reflux Disease (GERD) – Diagnosis and Coding

Gastroesophageal Reflux Disease (GERD) – Diagnosis and Coding

www.outsourcestrategies.com

Fax: (877)835-5442-5442

Call: 1-800-670-2809

Gastroesophageal Reflux Disease (GERD) is a condition in which stomach contents such as food or liquid leak back into the esophagus from the stomach.

This irritates the esophagus and results in heartburn, nausea, regurgitation and other symptoms. If left untreated, this condition leads to several serious complications such as esophagitis (painful and irritating inflammation of the esophagus), esophageal bleeding and ulcers, Barrett's esophagus, strictures, and even an increased risk of esophageal cancer.

If the gastroenterologist

suspects that his patient may have GERD, endoscopy or a trial of reflux medication will help to confirm the diagnosis. Advanced GERD tests include esophageal manometry and/or a pH monitoring. Medical coding for tests such as these requires excellent knowledge of the CPT codes; apart from this, gastroenterologists will also have to know whether the payer requires a modifier to be included in the medical claim.

ICD Coding for GERD

ICD-9

 530.81: Esophageal reflux

ICD-10

 K21: Gastro-esophageal reflux disease  K21.0: Gastro-esophageal reflux disease with esophagitis  K21.9: Gastro-esophageal reflux disease without esophagitis

www.outsourcestrategies.com

GERD -- CPT Coding

Here are the CPT codes for endoscopy procedures for GERD (Medicare).

43235: Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 43236: Esophagogastroduodenoscopy, flexible, transoral; with directed submucosal injection(s), any substance 43237: Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures 43238: Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures) 43239: Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple 43244: Esophagogastroduodenoscopy, flexible, transoral; with band ligation of esophageal/gastric varices 43245: Esophagogastroduodenoscopy, flexible, transoral; with dilation of gastric/duodenal stricture(s) (eg, balloon, bougie) 43246: Esophagogastroduodenoscopy, flexible, transoral; with directed placement of percutaneous gastrostomy tube

www.outsourcestrategies.com

43247: Esophagogastroduodenoscopy, flexible, transoral; with removal of foreign body(s) 43248: Esophagogastroduodenoscopy, flexible, transoral; with insertion of guide wire followed by passage of dilator(s) through esophagus over guide wire 43249: Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic balloon dilation of esophagus (less than 30 mm diameter)

A recent study published in the American Journal of Gastroenterology sees realtime MRI with high spatiotemporal resolution as a safe, rapid, robust, and clinically relevant imaging technique for the diagnosis of GERD and suggests that it may represent the next technical quantum that helps to understand this disease. The study says that though endoscopy can detect advanced esophagitis, the technique lacks sensitivity in recognizing pathological reflux. Non-invasive real-time MRI has great potential to diagnose causative pathologies that lead to GERD.

Treatment Options

Lifestyle and dietary changes are often recommended for most people requiring treatment for GERD. Medications are also provided in certain cases. Doctors recommend surgery as a treatment option for patients who do not respond well to lifestyle/dietary changes or medications or those who do not want to take medications continually to control their symptoms. Fundoplication is the most commonly performed surgery for GERD. This is done commonly with minimally invasive techniques using several small incisions, called laparoscopic surgery. www.outsourcestrategies.com

The CPT codes used to specify surgical procedures (Medicare) are as follows:

 43279: Laparoscopy, surgical, esophagomyotomy (Heller type), with fundoplasty, when performed  43280: Laparoscopy, surgical, esophagogastric fundoplasty (eg, Nissen, Toupet procedures)  43283: Laparoscopy, surgical, esophageal lengthening procedure (eg, Collis gastroplasty or wedge gastroplasty)  43325: Esophagogastric fundoplasty; with fundic patch (Thal-Nissen procedure)  43327: Esophagogastric fundoplasty partial or complete; laparotomy  43328: Esophagogastric fundoplasty partial or complete; thoracotomy

Each carrier specifies how to report GERD using the appropriate diagnosis and procedural codes. For example, the code 43283 should be reported in addition to the code for primary procedure in the case of Medicare. Healthcare providers should understand the coding guidelines specified by the carrier before reporting the diagnosis and procedures performed. A practical solution would be to rely upon professional medical coding services to save time and effort as well as ensure more coding accuracy.

www.outsourcestrategies.com

About Outsource Strategies International

Outsource Strategies International (OSI) is a reputable medical outsourcing solutions provider based in Tulsa, Oklahoma offering advanced medical billing and coding solutions for hospitals, physicians, physicians' groups, clinics and other healthcare entities. Find more details at: www.outsourcestrategies.com

Contact Us 8596 E. 101st Street, Suite H Tulsa, OK 74133 Main: (800) 670 2809 Fax: (877) 835-5442 E-mail: info@managedoutsource.com URL: www.outsourcestrategies.com