Q&A Code for History GERD

[Linda Charlwood]

Hello,

So is there a V code for history of reflux disease or do you just assign 530.81 when the documentation of past medical history lists reflux disease, stable, with hiatal hernia - 553.3

Thanks!!!
Linda

 

[Lori Woods]

I would think you could assign a v code if it is stated as a personal history. The only one I could find was v12.29 other endoctrine, metabolic & immunity disorders. I am still a student so I am curious also.

 

[Carolyn Heath]

I think that you would code the 530.81 along with the 553.3. Here is my thinking of why you would use the code 530.81: the documentation lists the reflux disease as stable even though it is listed in the past medical history list. The patient may still have it, but it is under control.

 

[Luna]

I would think you could assign a v code if it is stated as a personal history. The only one I could find was v12.29 other endoctrine, metabolic & immunity disorders. I am still a student so I am curious also.

I too wondered about whether a history code, if documentation supported it was a past condition, no longer active or being treated, would be appropriate. I came up with V12.70 Disease of digestive system; unspecified.

I'm not sure about the V12.29. We sometimes associate "metabolic" with digestion. Digestive pathologies include things like gastritis, GERD, peptic ulcer disease (PUD), hiatal hernia. Metabolic pathologies includes things like dehydration, hypercholesterolemia, hyperkalemia, ketoacidosis. I kind of see metabolic disorders as more associated with nutitional problems than a digestive problem. The body not able to properly process what digestion has already accomplished, the mechanical and chemical breakdown of food, and the process of extracting nutrients.

We'll keep putting our heads together. The right answer is out there. We're going to find it.

 

[Luna]

I think that you would code the 530.81 along with the 553.3. Here is my thinking of why you would use the code 530.81: the documentation lists the reflux disease as stable even though it is listed in the past medical history list. The patient may still have it, but it is under control.

I wondered too if the wording "stable" meant it was active but controlled or asymptomatic.

 

[Lori Woods]

It is confusing wording is everything isn't it. I wasn't sure if it would be v18.59 which is other digestive disorder if it even qualified as a history. I guess CCO will have to help us on this one.

 

[Luna]

It is confusing wording is everything isn't it. I wasn't sure if it would be v18.59 which is other digestive disorder if it even qualified as a history. I guess CCO will have to help us on this one.

Yes, it can be very confusing. Looking now at the difference between V12.70 and V18.59, it would be a matter of whether the history falls under a disease or a disorder. So, if a persons GERD status can truly be considered a "history of", would it fall under the disease category or the disorder category? Got some fun research ahead.

PS. GERD...I think the D definitely means disease.

 

[Luna]

Hello,

So is there a V code for history of reflux disease or do you just assign 530.81 when the documentation of past medical history lists reflux disease, stable, with hiatal hernia - 553.3

Thanks!!!
Linda

I did find this short webinar video CCO recently did on GERD involving the 530.81 code.
Also, looking back at your question Linda, are you saying the documentation is: patient history of reflux disease with hiatal hernia 553.3.
And so the question remains, is it appropriate to code a history of reflex in addition to the 553.3?

I know the 553.3 is for an acute condition, but not sure on the relfux....if that would be inclusive, or truly "history".

I want to let you know that earlier posts by me, I was just musing over my own curiosity about what history code would be appropraite for a true "history of" GERD.

I did find this video though. Not sure it will help, but it does address coding GERD.

 

[Mary Collins]

If the patient is not being treated for this condition during this admission, you shouldn't use "history of".

 

[Mary Collins]

According to the ICD-9-CM Official Guidelines for Coding and Reporting,

"Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring. " I don't think that GERD has the potential for recurrence if it has been treated before. Plus, if it has been treated before, it doesn't require continued monitoring. That's why I made the above comment.

 

[Linda Charlwood]

Hi Guys,

Thanks for the feedback. I was trying to find a V code for it because it was listed as stable, leading me to believe that it is in fact an issue that has been resolved so a history code (if there is one) seems appropriate. However I cannot locate one that seems like it would be right. I agree with Luna about V12.29 not fitting. I did also consider V12.70 that did seem like the only choice for the V codes especially because of the Hiatal hernia.

I think I remember reading somewhere (but I can't find where - read too many books by now) that if there is no personal history code to describe a condition to code it as if active. But I am not sure if it was for "personal history" or something else that I read that about. Also I know if it was a history of something that had no bearing on the current condition and did not affect treatment then it doesn't get coded anyway.

OK - as I am writing this it occured to me to check the PT's current medications (which there were a LOT) and she is in fact on meds for the GERD- soooooo the winner is 530.81!!

There it is......

 

[Linda Charlwood]

Hi Mary, didn't see your post till just now - was writing my reply above for a while, while researching. But GERD is a chronic recurring issue.

Thanks!

 

[Lori Woods]

Hello Mary! well I've been researching i think if i needed a code for a personal history of gerd I would use v12.79. Yes Luna D is for disease lol that's why 18.59 didn't make my first guess. Like Mary said though if it's not POA? I did watch the video but still couldn't decide lol. Mary my CMDT 2013 medical book says 80% of gerd patients experience a relapse of gerd symptoms within 3 months so I would say it does reoccur.

 

[Carolyn Heath]

Linda, both of us were right about the 530.81. Anytime you see a chronic condition in the personal medical history or past medical history, always check the current medication list.

 

[Linda Charlwood]

Hi Carolyn,
Yes I usually do - this was a 7 page chart and it was a BEAST - 21 ICD-9 codes and 13 CPT codes in total coded for it - I just overlooked it because it was a VERY confusing chart to code! If I had gone there 1st I would have had my answer but I was all over the place with this one. ;-)

 

[Lori Woods]

Well we all knew the gerd code was right we are all just wondering how we would code personal history of it. We need the Queen! lol.

 

[Mary Collins]

Thanks, ladies for clearing up the confusion!

 

[Linda Charlwood]

NP! that one was tough!!!!

 

[Ruth Sheets]

Here is a video blog post on GERD. https://www.cco.us/gastroesophageal-reflux-disease-gerd-video/