Clinical History:  Nausea, Epigastric Pain

Gross Description:  Received in formalin, designated "Gastric biopsies," are two fragments of light tan mucosal tissue, each measuring approximately 0.3 cm in greatest dimension, entirely submitted in a single cassette.

Microscopic Diagnosis:  Negative for intestinal metaplasia, dysplasia, or malignancy.

What are the appropriate diagnosis codes?

 Gastric Biopsy without Pathologic Findings

For diagnostic tests interpreted by a physician, code first any confirmed or definitive diagnoses documented in the pathology report. As in this scenario, when a definitive diagnosis is not rendered, the code selection is based on the clinical history or pre- post-operative diagnoses information provided by the referring physician. 

The ICD-9-CM and ICD-10 Coding Guidelines for Diagnostic Coding and Reporting Guidelines for Outpatient Services are very clear in directing the coder for this scenario; "codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider." 1 2

12014 ICD-9-CM Manual, American Medical Association, pages 46, 349, 413, 909, and 910.
22014 Draft  ICD-10-CM Manual, Optum, pages 28, 234, 251, and 817.

This commentary is a summary prepared by McKesson's Business Performance Services division and highlights certain changes, not all changes, in 2014 Current Procedural Terminology (CPT®) codes relating to the specialty of Pathology. This commentary does not supplant the American Medical Association's (AMA) current listing of CPT codes, its documentation in the annual CPT Changes publications, and other related publications from the AMA, which are the authoritative source for information about CPT codes. Please refer to your 2014 CPT® Code Book, annual CPT Changes publication, HCPCS Book and Payer Bulletins for additional information, including additions, deletions, changes, and interpretations that may not be reflected in this document.

CPT is a registered trademark of the American Medical Association ("AMA"). The AMA is the owner of all copyright, trademark and other rights to CPT and its updates.

Author - Female

About the author

Beth McDevitt, CPC is Compliance - National Pathology Coding Manager, Auditing, Pathology and Laboratory of McKesson Business Performance Services