Rate GERD Under DC 7203, Esophagus, Stricture of:
Rating
Documented history of recurrent or refractory esophageal stricture(s) causing dysphagia with at least one of the symptoms present: (1) Aspiration, (2) undernutrition, and/or (3) substantial weight loss as defined by § 4.112(a) and treatment with either surgical correction or percutaneous esophago-gastrointestinal tube (PEG tube)
80%
Documented history of recurrent or refractory esophageal stricture(s) causing dysphagia which requires at least one of the following (1) dilation 3 or more times per year, (2) dilation using steroids at least one time per year, or (3) esophageal stent placement
50%
Documented history of recurrent or refractory esophageal stricture(s) causing dysphagia which requires dilatation no more than 2 times per year
30%
Documented history of esophageal stricture(s) that requires daily medications to control dysphagia otherwise asymptomatic
10%
Documented history without daily symptoms or requirement for daily medications
0%
Note (#1): Findings must be documented by barium swallow, computerized tomography, or esophagogastroduodenoscopy
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Note (#2): Non-gastrointestinal complications of procedures should be rated under the appropriate system
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Note (#3): This diagnostic code applies, but is not limited to, esophagitis, mechanical or chemical; Mallory Weiss syndrome (bleeding at junction of esophagus and stomach due to tears) due to caustic ingestion of alkali or acid; drug-induced or infectious esophagitis due to Candida, virus, or other organism; idiopathic eosinophilic, or lymphocytic esophagitis; esophagitis due to radiation therapy; esophagitis due to peptic stricture; and any esophageal condition that requires treatment with sclerotherapy
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Note (#4): Recurrent esophageal stricture is defined as the inability to maintain target esophageal diameter beyond 4 weeks after the target diameter has been achieved
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Note (#5): Refractory esophageal stricture is defined as the inability to achieve target esophageal diameter despite receiving no fewer than 5 dilation sessions performed at 2-week intervals