K21.0: Gastro-esophageal reflux disease with esophagitis
K22.4: Dyskinesia of esophagus
0DJ08ZZ: Inspection of upper intestinal tract, via natural or artificial opening endoscopic
4A0B78Z: Measurement of gastrointestinal motility, via natural or artificial opening
To Locate Diagnosis Codes:
- K21.0: Index > Disease > gastro-esophageal reflux (GERD) > with esophagitis
- K22.4: Index > Dyskinesia > esophagus
- 0DJ08ZZ: Px Index > EGD (esophagogastroduodenoscopy) > 0DJ08ZZ. Even though the index gave you the entire code, you should still verify it by going to the correct table:
- Inspection: New terminology for ICD-10-PCS. Inspection is defined as “Visually and/or manually exploring a body part.”
- Approach: Entry of instrumentation through a natural or artificial external opening to reach and visualized the site of the procedure.
- Directions to locate the code by going directly to the tables:
- Determine the appropriate section, Med/Surg = 0
- Select the appropriate body system = D, Gastrointestinal System
- Select the appropriate root operation = J, Inspection, noting that the root procedures are listed alphabetically
- We now have the first 3 characters, 0DJ, which puts us in the correct table.
To assign the 4 remaining values for characters 4-7, you must identify the body part, the approach, and devices and qualifiers, if any:
- Body part = 0, Upper Intestinal Tract
- Approach = 8, Via natural or artificial opening, endoscopic
- Device = Z, No Device
- Qualifier = Z, No Qualifier = Z
- You have now built the code, 0DJ08ZZ
Procedure Location Directions Continued:
- 4A0B78Z: Px Index > Measurement > Gastrointestinal > Motility > 4A0B > locate table 4A0 and go across the row to finish building the code:
- Physiological Systems: The Administration section covers Administration, Placement, Measurement and Monitoring.
- Measurement: Measurement and Monitoring determines the level of a physiological or physical function repetitively over a period of time. Repeated readings over a period of time is considered MONITORING, while a single reading is considered MEASUREMENT. An esophageal motility study is typically done to evaluate suspected disorders of peristalsis of the esophagus.
- Function: The function and device values in the Measurement and Monitoring section describe body functions such as movement, flow, electricity, metabolism, pressure and temperature.
- Motility: An esophageal motility study (EMS) or esophageal manometry is a test to assess motor function of the upper esophageal sphincter (UES), esophageal body and lower esophageal sphincter (LES).
- Directions for locating the code going directly to the tables: The first question you may have is how do you know in which section the EMS is located. You know from the wording of the question that a motility study was done. Go to the Table of Contents and look for the Measurement and Monitoring section. Once you locate this section, you are given the first 3 characters, 4A0. O = Measurement/Monitoring; Physiological Systems = A, and the root operation, Measurement = 0. Now that you are in table 4A0, the next thing to look for is the appropriate body system, Gastrointestinal = 4A0B. Then determine the approach, function and qualifier, if any. We know that the opening was through the mouth (7), hence it is via a natural opening. You are given 3 choices for the function. Since you know this was a motility study, assign the 8 value. Because there are no qualifiers, assign the Z value. You have now built the code, 4A0B78Z.