Clinical Info/Hx:  70 y/o Medicare patient with GERD
Date of Service: 1-1-15
Gross Description:  Received in formalin, labeled esophageal biopsy, are three fragments of tan tissue measuring 0.2 to 0.6 cm in diameter. Submitted in toto -1 cassette.

Final Microscopic Diagnosis:  Glandular mucosa with Barrett’s esophagus - low grade dysplasia. No malignancy.

What are the appropriate CPT, CPT II, ICD-9, and ICD-10 codes for this scenario?

 Coding Barrett's Esophagus

Esophageal biopsy is a listed specimen in Current Procedural Terminology (CPT®) as 88305. 

Since the CPT and diagnosis coding combination of 88305 and 530.85 meet the requirements for PQRS measure #249, the report should be reviewed to determine if the requisite documentation regarding dysplasia is included in order to assign the appropriate PQRS/CPT II code. The 3126F should be assigned due to the documentation of Barrett’s esophagus with a statement regarding dysplasia defined as low-grade.

2015 CPT II Code Definition for 3126F:
Esophageal biopsy reports with the histological finding of Barrett’s mucosa that contains a statement about dysplasia (present, absent or indefinite, and if present, contains appropriate grading).

Important PQRS Reminders:

  • Providers must report on a minimum of nine measures. If less than nine measures apply, report on ALL measures that do apply.
  • Effective Jan. 1, 2015, CPT II codes 3125F, 3125F-1P and 3125F-8P are no longer accepted by Medicare. The new codes are 3126F, 3126F-1P, and 3126F-8P. 

Barrett’s esophagus with low-grade dysplasia. 
2015 ICD-9 Manual Alphabetic Index: Barrett’s esophagus 530.85

ICD-10 CM:
Barrett’s esophagus with low-grade dysplasia. 
2015 Draft ICD-10 Manual Alphabetic Index: Barrett’s esophagus – with dysplasia – low grade K22.710

  • K22.7 is the primary description of Barrett’s esophagus
  • 5th digit of 1 defines that dysplasia is present
  • 6th digit of 0 defines the dysplasia as low grade

2015 CPT Professional Edition Manual, American Medical Association (AMA), page 539.
2014 ICD-9-CM Professional Manual (AMA), pages 131, 818.
2015 Draft ICD 10-CM Manual (AMA), pages 35, 617.

Author - Female

About the author

Beth McDevitt, CPC is Compliance - National Pathology Coding Manager, Auditing, Pathology and Laboratory of web2pro Business Performance Services