ICD-10 Coding for Gastric Intestinal Metaplasia(K31.A11, K31.A21)
Complete ICD-10-CM coding and documentation guide for Gastric Intestinal Metaplasia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Gastric Intestinal Metaplasia
K31.APrimary Range
Gastric Intestinal Metaplasia
This range covers all codes related to gastric intestinal metaplasia, including variations based on location and presence of dysplasia.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| K31.A11 | Gastric intestinal metaplasia without dysplasia, antrum | Use when biopsy confirms GIM without dysplasia in the antrum. |
|
| K31.A21 | Gastric intestinal metaplasia with low-grade dysplasia | Use when histopathology confirms low-grade dysplasia in GIM. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for gastric intestinal metaplasia
Essential facts and insights about Gastric Intestinal Metaplasia
Primary ICD-10-CM Codes for intestinal metaplasia
Decision Criteria
clinical Criteria
- Biopsy confirms GIM without dysplasia in the antrum.
Applicable To
- Gastric intestinal metaplasia without dysplasia in the antrum
Excludes
- Barrett's esophagus (K22.70)
Clinical Validation Requirements
- Biopsy confirms gastric intestinal metaplasia without dysplasia in antrum
Code-Specific Risks
- Risk of using unspecified codes when specific site is documented.
Coding Notes
- Ensure the biopsy specifies the location and absence of dysplasia.
K31.A21 - Gastric intestinal metaplasia with low-grade dysplasia
Use when histopathology confirms low-grade dysplasia in GIM.
Applicable To
- Gastric intestinal metaplasia with low-grade dysplasia
Excludes
- Barrett's esophagus (K22.70)
Clinical Validation Requirements
- Histopathology shows low-grade dysplasia in gastric intestinal metaplasia.
Coding Notes
Document the grade of dysplasia clearly.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Helicobacter pylori as the cause of diseases classified elsewhere
B96.81Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Gastric Intestinal Metaplasia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code K31.A11.
Impact
Clinical: May lead to inappropriate surveillance intervals., Regulatory: Non-compliance with coding standards., Financial: Potential for incorrect billing and reimbursement.
Mitigation Strategy
Ensure biopsy reports are detailed., Train staff on documentation requirements.
Impact
Reimbursement: May lead to incorrect DRG assignment., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Query provider for specific location and dysplasia status.
Impact
Using unspecified codes when specific details are available.
Mitigation Strategy
Regular audits of documentation and coding practices.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Gastric Intestinal Metaplasia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Gastric Intestinal Metaplasia
Use these documentation templates to ensure complete and accurate documentation for Gastric Intestinal Metaplasia. These templates include all required elements for proper coding and billing.
Gastric Intestinal Metaplasia Surveillance
Specialty: GastroenterologyRequired Elements
- Endoscopy findings
- Biopsy locations
- Histopathology results
- Clinical correlation
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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