Peptic ulcers are the painful, open sores that develop on the inside lining of the stomach or the upper portion of the small intestine. The condition occurs when the acid in the digestive tract eats away the inner surface of the stomach or small intestine. The acid can create a painful open sore that bleeds. It is estimated that 1 in 10 people develop an ulcer at some point of time. In most cases, peptic ulcers develop due to a bacterial infection that eats away the protective lining of the digestive system. Billing and coding for this gastric condition can be challenging as the condition comes with different symptoms that can range from mild to severe. Outsourced medical coding services are a practical way to ensure accurate coding and claims submission for appropriate reimbursement.
Infection with the bacterium Helicobacter pylori (H. pylori) and long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) are the most common causes of peptic ulcers are. Several other factors such as family history of ulcers, stress, excessive alcohol consumption, smoking, and illness such as liver, kidney or lung disease, can increase the risk of this condition.
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Identifying Symptoms of Peptic Ulcer
Generally, small peptic ulcers do not produce any symptoms in the early phases. Burning stomach pain is one of the most common symptoms of peptic ulcers. Stomach acid makes the pain worse, as does having an empty stomach. The pain may become worse between meals and at night. Some of the common symptoms include –
- Feeling of fullness, bloating or belching
- Appetite changes
- Heartburn
- Intolerance to fatty foods
- Nausea or vomiting
- Trouble breathing
- Unexplained weight loss
- Vomiting or vomiting blood – which may appear red or black
- Dark blood in stools, or stools that are black or tarry
How is Peptic Ulcer Diagnosed?
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Gastroenterologists perform a detailed medical history evaluation and physical evaluation in order to detect peptic ulcer. In addition to evaluating symptoms, tests like endoscopy and tests for H. pylori may be ordered. Imaging tests such as X-rays and CT scans are also used to detect ulcers.
Treatment for peptic ulcers depends on the specific cause. Treatment focuses on killing the H. pylori bacterium (if present) and eliminating or reducing use of NSAIDs if possible, and prescription of medications to heal the ulcer. Medications for peptic ulcer include Proton pump inhibitors (PPI), Histamine receptor blockers (H2 blockers), Antibiotic medications (to kill H. pylori), prescription and over-the-counter medications omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), esomeprazole (Nexium) and pantoprazole (Protonix).
ICD-10 Codes to Report Peptic Ulcer
Diagnosis and treatment must be documented using the right medical codes. The ICD-10 diagnosis codes for peptic ulcer include –
- K27 Peptic ulcer, site unspecified
- K27.0 Acute peptic ulcer, site unspecified, with hemorrhage
- K27.1 Acute peptic ulcer, site unspecified, with perforation
- K27.2 Acute peptic ulcer, site unspecified, with both hemorrhage and perforation
- K27.3 Acute peptic ulcer, site unspecified, without hemorrhage or perforation
- K27.4 Chronic or unspecified peptic ulcer, site unspecified, with hemorrhage
- K27.5 Chronic or unspecified peptic ulcer, site unspecified, with perforation
- K27.6 Chronic or unspecified peptic ulcer, site unspecified, with both hemorrhage and perforation
- K27.7 Chronic peptic ulcer, site unspecified, without hemorrhage or perforation
- K27.9 Peptic ulcer, site unspecified, unspecified as acute or chronic, without hemorrhage or perforation
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Gastroenterology medical billing and coding can be challenging. Professional medical billing companies can ensure that claims are submitted in a timely manner with the correct codes.
If left untreated, peptic ulcers can lead to several complications like – internal bleeding, perforation in the stomach wall and gastric cancer. Most cases of peptic ulcers heal quickly with proper treatment. Quitting smoking and other tobacco use, limiting the frequent use of anti-inflammatory drugs, and eating a balanced diet can help prevent peptic ulcers from developing.
Healthcare providers need to remain well updated about the associated ICD-10 codes to report peptic ulcer correctly. Physicians can optimize reimbursement for the services they provide by utilizing the services of AAPC certified coders and experienced medical billers.
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