Clinical Policy Title: Upper gastrointestinal endoscopy

Transcription

1 Clinical Policy Title: Upper gastrointestinal endoscopy Clinical Policy Number: Effective Date: August 1, 2018 Initial Review Date: June 5, 2018 Most Recent Review Date: July 3, 2018 Next Review Date: July 2019 Related policies: CP# CP# Capsule endoscopy Gastroparesis evaluations Policy contains: Esophagogastroduodenoscopy. Upper endoscopy. Gastroscopy. Gastroesophageal reflux disease. Hematemesis. Gastrointestinal bleeding. ABOUT THIS POLICY: Select Health of South Carolina has developed clinical policies to assist with making coverage determinations. Select Health of South Carolina s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peerreviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by Select Health of South Carolina when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Select Health of South Carolina s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Select Health of South Carolina s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Select Health of South Carolina will update its clinical policies as necessary. Select Health of South Carolina s clinical policies are not guarantees of payment. Coverage policy Select Health of South Carolina considers the use of upper gastrointestinal endoscopy to be clinically proven and, therefore, medically necessary when any of the following criteria are met (Cohen, 2006; Early, 2012; Hirota, 2006): For diagnostic purposes, in the following situations: Persistent upper abdominal distress despite an appropriate trial of therapy. Upper abdominal distress associated with signs or symptoms suggestive of serious organic disease (such as weight loss and prolonged anorexia) or in members over age 45. Dysphagia or odynophagia of unknown cause. New onset of dyspepsia in members age 50 and older. Persistent or recurrent esophageal reflux signs or symptoms despite appropriate therapy. Persistent vomiting of unknown cause. Postoperative bariatric surgery with persistent nausea, vomiting, or abdominal distress despite counseling and behavior modification regarding diet. 1

2 Presence of systemic disease, the treatment of which would potentially be modified based on upper gastrointestinal pathology. Examples include patients with a history of gastrointestinal bleeding who are scheduled for organ transplantation; long-term anticoagulation; chronic nonsteroidal therapy for arthritis; or with cancer of the head or neck. Findings on X-ray of any of the following: A suspected neoplasm, for confirmation and biopsy for histology. Esophageal or gastric ulcer. Evidence of upper gastrointestinal tract obstruction or stricture. Presence of gastrointestinal bleeding, under any of the following conditions: When bleeding is active or recent. When surgical therapy is under consideration. When portal hypertension or aorto-enteric fistula is suspected. For presumed chronic blood loss and for iron deficiency anemia when colonoscopy findings are negative. When the sampling of tissue or fluid is indicated. After caustic agent ingestion, to assess acute injury. During surgery, to identify the location or clarify the pathology of a lesion or to evaluate anatomic reconstructions. In members with a familial adenomatous polyposis syndrome. To evaluate potential upper gastrointestinal role in suspected lower gastrointestinal disorders such as celiac disease or in pediatric inflammatory bowel disease. For therapeutic purposes, in any of the following conditions: To treat bleeding from lesions including ulcers, tumors, vascular malformations (for example, electrocoagulation, heater probe, injection therapy, or laser photocoagulation). To perform sclerotherapy for bleeding from esophageal or proximal gastric varices or banding of varices. To remove a foreign body. To remove selected polypoid or submucosal lesions. For placement of feeding tubes (oral, percutaneous endoscopy gastrostomy, percutaneous endoscopic jejunostomy). For dilation of stenotic lesions (e.g., with dilating systems employing guidewires or with transendoscopic balloon dilators). To provide palliative therapy of stenosing neoplasms (such as laser, stent placement, and bipolar electrocoagulation). For management of gastroduodenal dysmotility when symptoms persist despite optimal medical and dietary management. For treatment of achalasia. For dilation in adult members with eosinophilic esophagitis who have a dominant esophageal stricture or ring and remain symptomatic despite medical therapy. 2

3 Endoscopic resection for members with Barrett s esophagus, in the absence of life-limiting comorbidities, is medically necessary with any of the following findings: Low-grade dysplasia. Flat high-grade dysplasia. Intestinal metaplasia. Endoscopic resection or radiofrequency ablation for members without life-limiting comorbidities and stage T1a esophageal adenocarcinoma. Screening (periodic diagnostic) upper gastrointestinal endoscopy may be indicated for a medically appropriate number of procedures in the following active or symptomatic conditions: For follow up of members with portal hypertension or compensated cirrhosis if any of the following criteria are met: Finding of small varices and high-risk stigmata, follow-up every one to two years. With no finding of varices, follow up every two to three years. In members with history of alcohol abuse or decompensated liver disease, follow-up annually. For follow up of selected esophageal, gastric, or stomal ulcers to demonstrate healing. The frequency of follow-up examinations is variable, but every two to four months until healing is demonstrated is reasonable. For follow up in members with prior adenomatous gastric polyps. The approximate frequency of follow-up examinations would be every one to four years, depending on the clinical circumstances. Some members with sessile polyps would initially require surveillance every six months initially). For follow up for adequacy of prior sclerotherapy or banding of esophageal varices. The approximate frequency of follow-up procedures varies widely depending on the state of the member. Every six to 24 months is reasonable after completion of the initial sclerotherapy/banding sessions have been completed. For follow up of Barrett's esophagus, approximately every one to two years with biopsies, unless dysplasia or atypia is demonstrated, in which case a repeat biopsy in two to three months may be indicated. For follow up in members with familial adenomatous polyposis, the recommended approximate frequency of follow up is every two to four years. However, the presence of gastric adenomas or adenomas of the duodenum may indicate more frequent follow up of every six to 12 months. Limitations: Upper gastrointestinal endoscopy is not medically necessary for the following: Screening of asymptomatic upper gastrointestinal tracts of members at average risk. Follow-up screening for Barrett s esophagus after the previous examination findings were negative for Barrett s esophagus. 3

4 Screening for aerodigestive cancer. Follow-up of any of the following: Healed benign disease, such as gastric or duodenal ulcer, or esophagitis. Gastric atrophy. Pernicious anemia. Fundic gland or hyperplastic polyps. After radiographic findings of any of the following: Sliding hiatal hernia, asymptomatic or uncomplicated. Uncomplicated duodenal ulcer that has responded to treatment. Deformed duodenal bulb in the absence of symptoms or when symptoms respond to ulcer therapy. Confirming eradication of Helicobacter pylori eradication. To evaluate isolated pylorospasm, known congenital hypertrophic pyloric stenosis, constipation and encopresis, or inflammatory bowel disease responding to therapy. Prior to bariatric or non-gastroesophageal surgery in asymptomatic individuals. Metastatic adenocarcinoma of unknown primary site when the results will not alter management. To obtain tissue samples from endoscopically normal tissue to diagnose reflux disease or exclude Barrett s esophagus in adults. To evaluate symptoms considered functional in origin. To evaluate benign-appearing, uncomplicated duodenal ulcers identified on radiologic imaging. When there is clinical evidence of acute perforation. Upper gastrointestinal endoscopy is contraindicated in conditions including shock, peritonitis, fulminant colitis, perforated viscus (e.g., esophagus, stomach, intestine), acute myocardial infarction (unless there is an active life-threatening hemorrhage), and severe cardiac decompensation. Additionally, relative contraindications include individuals who are not fully conscious, alert, and cooperative, and who have cardiac arrhythmias or recent myocardial ischemia (Chan, 2017). Alternative covered services: X-ray. Ultrasound. Capsule endoscopy. Ambulatory esophageal ph monitoring. Background Upper gastrointestinal endoscopy, also known as esophagogastroduodenoscopy, upper endoscopy, or gastroscopy, is a procedure in which a flexible tube known as a fiberoptic endoscope, which may have video capacity, is introduced into the upper gastrointestinal system (National Institute of Diabetes and Digestive and Kidney Diseases, 2017). This transmits a magnified image that is used to examine tissue, 4

5 visualize the area while extracting biopsies, or perform a therapeutic procedure. The areas that can be visualized during the procedure are the esophagus, stomach, and upper intestine (duodenum). The procedure can be performed on an outpatient basis, usually while a patient is sedated. It is generally a brief procedure lasting 15 to 30 minutes. The risks from the procedure, which are considered low, include bleeding, perforation of the lining of the upper gastrointestinal tract, and a reaction to the sedative. Gastrointestinal endoscopy is a keystone of the evaluation and management of gastrointestinal disease (Sivak, 2006). Upper gastrointestinal endoscopy is used to identify the causes of symptoms such as abdominal pain or bleeding, discomfort eating or swallowing, heartburn, nausea, vomiting, and indigestion. Upper gastrointestinal endoscopy is useful in diagnosing conditions including esophagitis, Schatzki s ring (lower esophageal ring or esophagastric ring), inflammation of the stomach or duodenum, ulcer, polyps, diverticula, and other abnormalities including mucosal tears, obstructions, strictures, and tumors. The procedure can also be used therapeutically to treat conditions such as bleeding due to ulcers, to remove foreign objects, polyps, or growths, to widen strictures with a small balloon, and to place feeding tubes. In addition, the procedure is used to screen for possible disease in symptomatic individuals or individuals at risk for gastrointestinal disease, and to follow up on treated conditions. Searches Select Health of South Carolina searched PubMed and the databases of: UK National Health Services Centre for Reviews and Dissemination. Agency for Healthcare Research and Quality s National Guideline Clearinghouse and other evidence-based practice centers. The Centers for Medicare & Medicaid Services. We conducted searches on April 30, Search terms were: upper gastrointestinal endoscopy, esophagogastroduodenoscopy, upper endoscopy, and gastroscopy. We included: Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. Findings 5

6 We were unable to identify many publications on the comparative efficacy of upper gastrointestinal endoscopy for the multiple indications for which it is commonly used, or on safety of the procedure. The coverage indications for this policy are based on several professional guidelines, primarily developed by the American Society of Gastrointestinal Endoscopists. Their publication on the indications for gastrointestinal endoscopy (Early, 2012) is the main source for the coverage policy, along with earlier publications on quality indicators (Cohen, 2006) and premalignant conditions (Hirota, 2006). The need for effective screening and diagnostic tools evolve as disease trends shift. Increases in obesity and gastroestophageal reflux disease are provoking some shifts in how upper gastrointestinal endoscopy is used. Upper gastrointestinal endoscopy is of limited value in diagnosing gastroesophageal reflux disease. Instead, ambulatory esophageal ph monitoring is more sensitive since it estimates distal esophageal acid exposure and can show the relationship between acid reflux and its symptoms. A cost-effectiveness analysis examined the clinical and economic impact of performing upper gastrointestinal endoscopies in patients with indications suggesting they should have the procedure in comparison with those without an indication for the procedure (DiGiulio, 2009). The results showed that to detect one case of cancer among those with appropriate indications, 41 procedures had to be performed, while 753 had to be performed in those without an indication in order to find one case of cancer. To prevent one death related to gastroesophageal cancer, 571 procedures had to be carried out in those with indications, while 11,111 procedures had to be carried out in those without indications for the procedure. Per life-year gained, the incremental cost-effectiveness ratios of appropriate and inappropriate upper endoscopies, as compared to a policy of not referring patients for endoscopy, were $16,577 in those with an indication for the procedure and $301,203 in those without an indication for the procedure. This analysis does not take into account the risk of procedures in those without an indication. Policy updates: None. Summary of clinical evidence: Citation Pimenta-Melo (2016) Missing rate for gastric cancer Content, Methods, Recommendations Key points: A total of 22 studies were included in this meta-analysis. The pooled negative predictive value was 99.7% (95% confidence interval %). The missed gastric cancer proportion was 9.4% (95% confidence interval %), and was 10.0% in studies including patients with negative findings followed over time. The proportion was 8.3% in studies including patients with gastric cancer, and 23.3% in studies evaluating the proportion of missed synchronous lesions. Missed cancers were mainly located in the gastric body and most were 6

7 Citation American Society for Gastrointestinal Endoscopy (2014) Endoscopy in evaluation and management of dysphagia Ford (2010) Content, Methods, Recommendations adenocarcinomas. Predictors of diagnostic failure were younger age (<55 years), female sex, marked gastric atrophy, gastric adenoma or ulcer, and inadequate number of biopsy fragments. The authors conclude that upper gastrointestinal endoscopy is a very effective method to rule out gastric cancer, but that one in 10 cancers are potentially missed. Interestingly, lesions were more often missed in the body and, therefore, a more rigorous protocol for endoscopy and biopsy should be implemented worldwide. Key points: Endoscopy is indicated in patients with dysphagia to determine the underlying etiology, exclude malignant and premalignant conditions, assess the need for therapy, and perform therapy, such as dilation. Esophageal dilation is a therapeutic procedure performed for the management of dysphagia. The primary indication for dilation is to provide immediate and durable symptomatic relief of dysphagia. Safety and efficacy have been confirmed in both adults and the pediatric population. Key points: Prevalence of clinically significant endoscopic findings in dyspepsia This systematic review and meta-analysis identified 151 publications that reported the prevalence of dyspepsia. Of these, nine reported prevalence of endoscopic findings among 5,389 total participants. Erosive esophagitis was the most common abnormality encountered (pooled prevalence 13.4%) followed by peptic ulcer (pooled prevalence 8.0%). The only finding encountered more frequently in individuals with dyspepsia, compared with those without, was peptic ulcer (odds ratio, 2.07; 95% confidence interval, ). The prevalence of erosive esophagitis was lower when the Rome criteria were used to define dyspepsia compared with a broad definition (6% versus 20%). Erosive esophagitis was the most common finding encountered at endoscopy for dyspepsia. The prevalence was lower when the Rome criteria were used to define dyspepsia. Only peptic ulcer was found to be more common in individuals with dyspepsia. DiGiulio (2009) Cost-effectiveness of upper gastrointestinal endoscopy according to appropriateness of the indication Key points: The authors constructed a decision analysis model to compare a strategy of not referring patients for upper endoscopy (with either an appropriate or inappropriate indication) with a policy of carrying out the requested upper endoscopy. Cancer prevalence in appropriate and inappropriate procedures was estimated using a systematic review of the literature. Costs of the procedure and cancer care were estimated from Medicare reimbursement data. The number of appropriate and inappropriate procedures required to detect one case of cancer was 41 and 753, respectively. To prevent one gastroesophageal cancer-related death, the numbers were 571 and 11,111, respectively. The incremental cost-effectiveness ratios of appropriate and inappropriate upper endoscopies as compared to a policy of not referring patients for endoscopy were $16,577 and $301,203, respectively, per life-year gained. The authors conclude that for inappropriate upper endoscopies, the very low likelihood of cancer and the relatively high costs associated with this procedure argue against endoscopic referral. 7

8 References Professional society guidelines/other: American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc Jan;71(1):1-9. doi: /j.gie ASGE Standards of Practice Committee, Pasha SF, Acosta RD, et al. The role of endoscopy in the evaluation and management of dysphagia. Gastrointest Endosc. 2014;79(2): Chan, WW. Endoscopy. Merck Manual Professional Version. Updated February, Accessed April 30, Cohen J, Safdi MA, Deal SE, et al. Quality indicators for esophagogastroduodenoscopy. Gastrointest Endosc. 2006;63(4):S10-S15. Early DS, Ben-Menachem T, Decker GA, et al. Appropriate use of GI endoscopy. Gastrointest Endosc. 2012;75(6): Faigel DO, Pike IM, Baron TH, et al. Quality indicators for gastrointestinal endoscopic procedures: an introduction. Gastrointest Endosc. 2006;63(4):S3-S9. Hirota WK, Zuckerman MJ, Adler DG, et al; Standards of Practice Committee, American Society for Gastrointestinal Endoscopy. ASGE guideline: The role of endoscopy in the surveillance of premalignant conditions of the upper GI tract. Gastrointest Endosc. 2006;63(4): National Institute of Diabetes and Digestive and Kidney Diseases. Upper GI endoscopy. National Institutes of Health website. July, Accessed April 30, Spechler SJ, Sharma P, Souza RF, Inadomi JM, Shaheen NJ. American Gastroenterological Association Technical Review on the Management of Barrett s Esophagus. Gastroenterology. 2011;140(3):e18-e13. doi: /j.gastro Peer-reviewed references: Cena M, Gomez J, Alyousef T, Trohman RG, Pierko K, Agarwal R. Safety of endoscopic procedures after acute myocardial infarction: a systematic review. Cardiol J. 2012;19(5): Di Giulio E, Hassan C, Pickhardt PJ, et al. Cost-effectiveness of upper gastrointestinal endoscopy according to the appropriateness of the indication. Scand J Gastroenterol. 2009;44(4):

9 Ford AC, Marwaha A, Lim A, Moayyedi P. What is the prevalence of clinically significant endoscopic findings in subjects with dyspepsia? Systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2010;8(10): , 837.e Kwan V. Advances in gastrointestinal endoscopy. Internal medicine journal. 2012;42(2): Sivak MV. Gastrointestinal endoscopy: past and future. Gut. 2006;55(8): CMS National Coverage Determinations (NCDs): Endoscopy. Longstanding national coverage determination, the effective date of which has not been published. p=title&keywordsearchtype=and&bc=gaaaacaaaaaa&. Accessed April 30, Local Coverage Determinations (LCDs): L35350 Upper gastrointestinal endoscopy (diagnostic and therapeutic). Revision effective date October 1, KeyWord=upper+gastrointestinal+endoscopy&KeyWordLookUp=Title&KeyWordSearchType=And&bc=g AAAACAAAAAA&. Accessed April 30, L34434 Upper gastrointestinal endoscopy and visualization. Revision effective date February 26, KeyWord=upper+gastrointestinal+endoscopy&KeyWordLookUp=Title&KeyWordSearchType=And&bc=g AAAACAAAAAA&. Accessed April 30, InterQual LOC: Acute adult. InterQual All categories. Anemia/bleeding. LOC: Acute adult. InterQual All categories. General medical. CP: Procedures. InterQual Specialized procedures. Endoscopy, upper gastrointestinal. CP: Procedures. InterQual Specialized procedures. Endoscopy, upper gastrointestinal (pediatric). Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. 9

10 CPT Code Description Comments Esophagoscopy rigid trnso dx Esophagoscp rig trnso inject Esophagoscp rig trnso biopsy Esophagoscp rig trnso rem fb Esophagoscopy rigid balloon Esophagoscp guide wire dilat Esophagoscopy flex dx brush Esophagosc flex trnsn biopsy Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Esoph scope w/submucous inj Esophagoscopy, flexible, transoral; with biopsy, single or multiple Esoph scope w/sclerosis inj Esophagus endoscopy/ligation Esoph optical endomicroscopy Egd esophagogastrc fndoplsty Esophagoscop mucosal resect Esophagoscop stent placement Esophagoscopy retro balloon Esophagosc dilate balloon Esophagoscopy flex remove fb Esophagoscopy lesion removal Esophagoscopy snare les remv Esophagoscopy balloon <30mm Esoph endoscopy dilation Esophagoscopy control bleed Esophagoscopy lesion ablate Esophagoscop ultrasound exam Esophagoscopy w/us needle bx Egd balloon dil esoph30 mm/> Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) Uppr gi scope w/submuc inj Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s), (includes endoscopic ultrasound examination limited to the esophagus, stomach or duodenum, and adjacent structures) Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple Egd w/transmural drain cyst Egd tube/cath insertion Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound-guided intramural or transmural fine needle aspiration/biopsy(s) 10

11 CPT Code Description Comments (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis) Egd injection varices Egd varices ligation Egd dilate stricture Egd place gastrostomy tube Egd remove foreign body Egd guide wire insertion Esoph egd dilation <30 mm Egd cautery tumor polyp Egd remove lesion snare Egd optical endomicroscopy Egd us transmural injxn/mark Egd endo mucosal resection Egd control bleeding any Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum or a surgically altered stomach where the jejunum is examined distal to the anastomosis Ercp w/specimen collection Endo cholangiopancreatograph Endo cholangiopancreatograph Ercp sphincter pressure meas Ercp remove duct calculi Ercp lithotripsy calculi Egd endoscopic stent place Egd lesion ablation Ercp duct stent placement Ercp remove forgn body duct Ercp stent exchange w/dilate Ercp ea duct/ampulla dilate Ercp lesion ablate w/dilate Remove esophagus obstruction ICD-10 Code Description Comments C15.3-C17.9 Malignant neoplasm of esophagus, stomach, small intestines C32.0-C33 Malignant neoplasm of larynx and trachea D51.0 Vitamin B12 deficiency anemia due to intrinsic factor deficiency K21.9 Gastro-hyphenesophageal reflux disease without esophagitis K K Barrett's esophagus C C81.03 Nodular lymphocyte predominant Hodgkin lymphoma involving lymph nodes of head, face, neck, C C81.13 Nodular sclerosis classical Hodgkin lymphoma involving lymph nodes of head, face, neck, 11

12 ICD-10 Code Description Comments C C81.23 Mixed cellularity classical Hodgkin lymphoma involving lymph nodes of head, face, neck, C C81.33 Lymphocyte-hyphendepleted classical Hodgkin lymphoma involving lymph nodes of head, face, neck, C C84.43 Lymphocyte-hyphenrich classical Hodgkin lymphoma involving lymph nodes of head, face, neck, C C81.73 Other classical Hodgkin lymphoma involving lymph nodes of head, face, neck, C C81.93 Hodgkin lymphoma, unspecified, involving lymph nodes of head, face, neck, C , C , C , C , Follicular lymphoma involving lymph nodes of head, face, neck, intrathoracic and C , intra-hyphenabdominal C , C , C , C C C83.03 Small cell B-hyphencell lymphoma involving lymph nodes of head, face, neck, C C83.13 Mantle cell lymphoma involving lymph nodes of head, face, neck, intrathoracic and intra-hyphenabdominal C C83.33 Diffuse large B-hyphencell lymphoma involving lymph nodes of head, face, neck, C C81.53 Lymphoblastic (diffuse) lymphoma involving lymph nodes of head, face, neck, C C83.73 Burkitt lymphoma involving lymph nodes of head, face, neck, intrathoracic and intra-hyphenabdominal C C83.83 Other non-hyphenfollicular lymphoma involving lymph nodes of head, face, neck, C C83.93 Non-hyphenfollicular (diffuse) lymphoma involving lymph nodes of head, face, neck, C C84.03 Mycosis fungoides involving lymph nodes of head, face, neck, intrathoracic and intra-hyphenabdominal C84.41 Mycosis fungoides involving lymph nodes of head, face, neck, intrathoracic and intra-hyphenabdominal C C84.63, C C84.73 C84.a1- C84.a3 C C85.13 C C85.23 Anaplastic large cell lymphoma involving lymph nodes of head, face, neck, Cutaneous T-hyphencell lymphoma, unspecified, involving lymph nodes of head, face, neck, Unspecified B-hyphencell lymphoma involving lymph nodes of head, face, neck, Mediastinal (thymic) large B-hyphencell lymphoma involving lymph nodes of head, face, neck, 12

13 ICD-10 Code Description Comments C C85.83 Other specified types of non-hyphenhodgkin lymphoma involving lymph nodes of head, face, neck, C C85.93 Non-hyphenHodgkin lymphoma, unspecified, involving lymph nodes of head, face, neck, C86.0, C86.2- C86.3 Other specified types of T/NK-hyphencell lymphoma C C91.42 Hairy cell leukemia C C96.29 Malignant mast cell tumor C96.a Histiocytic sarcoma C96.z Other specified malignant neoplasms of lymphoid, hematopoietic and related tissue C96.9 Malignant neoplasm of lymphoid, hematopoietic and related tissue, unspecified D12.0-D12.6 Benign neoplasm of colon D13.0-D13.39 Benign neoplasm of esophagus, stomach, duodenum and of other and unspecified parts of small intestine D37.8-D37.9 Neoplasm of uncertain behavior of other specified and unspecified digestive organs D50.0-D50.9 Iron deficiency anemia D62 Acute posthemorrhagic anemia I50.00-I50.11 Esophageal varices K20.0-K21.0 Esophagitis K21.9 Gastro-hyphenesophageal reflux disease without esophagitis K K22.11 Ulcer of esophagus K22.3 Perforation of esophagus K22.5 Diverticulum of esophagus, acquired K K Barrett's esophagus K25.0-K25.9 Gastric ulcer K26.0-K26.9 Duodenal ulcer K27.0-K27.9 Peptic ulcer K28.0-K28.9 Gastrojejunal ulcer K30 Functional dyspepsia K31.7 Polyp of stomach and duodenum K76.6 Portal hypertension K92.0-K92.2 Hematemesis, melena and unspecified gastrointestinal hemorrhage Q26.6 Portal vein-hyphenhepatic artery fistula R R10.12 Pain localized to upper abdomen, right and left upper quadrant R R10.33 Epigastric and periumbilical pain R11.10 Vomiting, unspecified R13.0-R13.19 Aphagia and dysphagia R93.3 Abnormal findings on diagnostic imaging of other parts of digestive tract 13

14 ICD-10 Code Description Comments R93.5 Abnormal findings on diagnostic imaging of other abdominal regions, including retroperitoneum T54.0x1+- T54.94x+ Toxic effect of corrosive substances [acute injury after caustic ingestion] T57.1x1+- T57.1x4+ Toxic effect of phosphorus and its compounds [acute injury after caustic ingestion] HCPCS Level II Code N/A Description Not Applicable Comments 14