June 12, 2006

Coding for Esophagitis
For The Record
Vol. 18 No. 12 P. 38

Esophagitis is the irritation or swelling of the esophageal lining. It can be caused by an infection or irritation of the esophagus. Some common infections causing esophagitis include the following:

• bacteria;

• viruses such as herpes or cytomegaloviral disease; and

• fungus such as Candida.

Common irritations causing esophagitis include the following:

• gastroesophageal reflux disease (GERD);

• vomiting;

• surgery;

• anti-inflammatory meds;

• toxic substance ingestion;

• hernia; and

• radiation injury.

Esophagitis is classified to subcategory 530.1. A fifth-digit subclassification is necessary to identify the specific type of esophagitis as follows:

• 530.10, Esophagitis unspecified;

• 530.11, Reflux esophagitis;

• 530.12, Acute esophagitis; and

• 530.19, Other esophagitis.

If the condition is documented as candidal esophagitis or esophagitis due to oral thrush, assign code 112.84.

GERD is the backflow of acid-containing fluid from the stomach to the esophagus. If a patient has GERD and also has esophagitis that is caused by something other than reflux, two codes are assigned—one code for the GERD (530.81) and the appropriate code for the esophagitis (530.1x). If the patient has GERD with reflux esophagitis, only assign code 530.11 (AHA Coding Clinic for ICD-9-CM, 1995, fourth quarter, page 82, and 1993, fourth quarter, page 27).

Ulcerative esophagitis is assigned to code 530.19. The code assignment is dependent on the physician documentation. If the physician documents esophageal ulcer and ulcerative esophagitis, assign codes 530.2x and 530.19. “Ulcerative esophagitis is not the same as an ulcer of the esophagus. Sequencing will depend on the circumstances of admission. Although ulcerative esophagitis may involve inflammation, redness, and rawness of the esophagus, rarely is an actual ulcer present” (AHA Coding Clinic for ICD-9-CM, 2001, third quarter, pages 10-11). However, if the physician specifically documents the presence of an esophageal ulcer with the ulcerative esophagitis, it is appropriate to assign a code for the esophageal ulcer.

Symptoms
The following are common symptoms of esophagitis:

• difficulty swallowing;

• painful swallowing;

• heartburn;

• mouth sores;

• sensation of something being stuck in the throat;

• nausea; and

• vomiting.

Diagnosis
To confirm the diagnosis of esophagitis, the physician may perform the following diagnostic tests:

• upper endoscopy;

• biopsy;

• upper gastrointestinal series such as a barium swallow; and

• culture.

Treatment
Medications are typically the first line of treatment for esophagitis. The physician may order medications that block acid production. In addition, antibiotics, antifungal, or antiviral medications may be prescribed to treat an infection causing the esophagitis. Corticosteroids may also be given to reduce inflammation. The physician may perform an endoscopy to remove any blockage. If the esophagitis is severe, surgery may be performed to remove the damaged part of the esophagus.

Complications
If the esophagus is left untreated, the following complications may occur:

• problems with swallowing (787.2);

• ulcers of the esophagus (530.2x);

• scarring of the esophagus (530.3);

• Barrett’s esophagus (530.85);

• stricture of the esophagus (530.3);

• esophageal hemorrhage (530.82);

• malnutrition (260-263.9); and

• dehydration (276.51).

Coding and sequencing for esophagitis are dependent on the physician documentation in the medical record and application of the Official Coding Guidelines for inpatient care. Also, use specific AHA Coding Clinic for ICD-9-CM and American Medical Association CPT Assistant references to ensure complete and accurate coding.

— This information was prepared by Audrey Howard, RHIA, of 3M Consulting Services. 3M Consulting Services is a business of 3M Health Information Systems, a supplier of coding and classification systems to nearly 5,000 healthcare providers. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payors as the result of the misuse of this coding information. More information about 3M Health Information Systems is available at www.3mhis.com or by calling 800-367-2447.

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