Find information on tortuous esophagus diagnosis, including clinical documentation tips, medical coding guidelines (ICD-10-CM), and healthcare best practices. Learn about symptoms, causes, and treatment options for tortuous esophagus, and improve your understanding of this anatomical variant. Explore resources for accurate medical coding and compliant clinical documentation related to esophageal tortuosity.
Also known as
Other congenital malformations of esophagus
Includes congenital esophageal stenosis, webs, or tortuosity.
Other diseases of esophagus
Covers other specified esophageal conditions not classified elsewhere.
Other ill-defined symptoms and signs
May be used for unusual symptoms like dysphagia due to esophageal tortuosity if no other specific code applies.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the tortuous esophagus symptomatic?
When to use each related code
| Description |
|---|
| Tortuous esophagus |
| Esophageal web |
| Esophageal stricture |
Coding unspecified esophageal tortuosity (Q39.89) when a more specific type exists, leading to under-reporting severity and impacting reimbursement.
Overlooking associated conditions like dysphagia or hiatal hernia, which are crucial for accurate risk adjustment and patient care.
Coding tortuous esophagus based solely on imaging without sufficient clinical documentation supporting the diagnosis and its impact on the patient.
Patient presents with symptoms suggestive of tortuous esophagus, including dysphagia, regurgitation, and occasional chest pain. The patient describes the dysphagia as intermittent and occurring with both solids and liquids. Regurgitation is described as non-acidic and containing undigested food. Physical examination is unremarkable. Review of systems is negative for significant weight loss, odynophagia, or hematemesis. Differential diagnoses include achalasia, esophageal spasm, and gastroesophageal reflux disease (GERD). To evaluate for esophageal motility disorder and structural abnormalities, a barium swallow study was ordered. The barium swallow revealed a markedly elongated and tortuous esophagus with multiple redundant loops, confirming the diagnosis of tortuous esophagus. Esophageal manometry may be considered for further evaluation of esophageal motility. The patient was educated on dietary modifications, including smaller, more frequent meals and thorough chewing. Conservative management with lifestyle adjustments will be initiated. Follow-up is scheduled to assess symptom improvement and discuss further management options if necessary. ICD-10 code Q39.89 (Other congenital malformations of esophagus) may be appropriate depending on the etiology, and CPT codes for the barium swallow (74240) and potential esophageal manometry (91010) should be used for billing purposes. This documentation supports medical necessity for diagnostic testing and ongoing management of tortuous esophagus.