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Medical Policy
Esophagogastroduodenoscopy (EGD)/Upper Gastrointestinal Endoscopy
Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History
• Endnotes Policy Number: 202 BCBSA Reference Number: N/A
NCD/LCD: N/A Related Policies
• Adjunctive Techniques for Screening and Surveillance of Barrett Esophagus and Esophageal
Dysplasia #841
• Chromoendoscopy as an Adjunct to Colonoscopy #904 • Endoscopic Radiofrequency Ablation or Cryoablation for Barretts Esophagus #218 • Medical and Surgical Management of Obesity including Anorexiants #379 • Serological Diagnosis of Celiac Disease #138 • Serum Antibodies for the Diagnosis of Inflammatory Bowel Disease #551 • Surgical and Transesophageal Endoscopic Procedures to Treat Gastroesophageal Reflux Disease

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• Wireless Capsule Endoscopy for Gastrointestinal (GI) Disorders #185 Policy1 Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Esophagogastroduodenoscopy (EGD)/Upper Gastrointestinal Endoscopy is considered MEDICALLY NECESSARY for the following:

Evaluation and Diagnosis • Symptoms o Upper abdominal symptoms (e.g., dyspepsia, heartburn, regurgitation, non-cardiac pain, nausea) ▪ Recent onset symptoms in patients >50 years. ▪ Associated with anorexia, early satiety, weight loss, GI bleeding.
▪ If under age 50, symptoms >8 weeks and refractory to medical acid suppression AND negative non-invasive H. pylori testing (e.g., stool antigen, urea breath test) o Dysphagia, odynophagia, or food impaction. o Persistent vomiting of unknown cause. o GI bleeding:

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▪ Active or recent bleeding (e.g., hematemesis, melena). ▪ Presumed chronic blood loss with iron deficiency (with or without anemia) when upper GI source suspected or colonoscopy negative. • Suspected or Diagnosed Conditions: o Acute caustic ingestion for injury assessment and management o Esophagitis o Upper GI obstruction or stricture. o Radiologically demonstrated lesions requiring histologic confirmation (e.g., mass, neoplastic lesions, ulcers, strictures). o Esophageal cancer post-resection with signs/symptoms of local/regional recurrence. o Portal hypertension with or without cirrhosis to assess for esophageal varices. o Celiac disease (suspected or for confirmation). o Differentiation of Crohn’s disease from ulcerative colitis. o Conditions requiring upper GI fluid sampling or tissue biopsy for diagnosis/evaluation. o Esophageal physiology assessment using impedance planimetry. o Placement of wireless pH capsule for esophageal/extraesophageal reflux symptoms without severe erosive reflux disease.

Treatment and Management • Removal of foreign bodies or polypoid lesions. • Treatment of bleeding lesions (e.g., ulcers, tumors, vascular anomalies) via: o Electrocoagulation, heat probe, laser, or injection therapy. o Banding or sclerotherapy of esophageal varices. • Dilation of stenotic lesions.
• Palliative treatment of stenosing neoplasms (e.g., laser, electrocoagulation, stent placement). • Eosinophilic esophagitis or eosinophilic GI diseases for disease activity assessment and management. • Achalasia management. • Placement of feeding or drainage tubes (e.g., peroral, percutaneous endoscopic gastrostomy, jejunostomy). • Endoscopic therapy for Barrett’s esophagus and/or gastric intestinal metaplasia.

Screening for High-Risk Conditions • Barrett’s Esophagus: o Chronic GERD (≥5 years) without known Barrett’s; repeat screening not necessary if first EGD is negative. o Severe erosive esophagitis to assess for mucosal healing and screen for Barrett’s esophagus. No longer necessary when mucosa is healed and if initial screen for Barrett’s is negative • Gastric/Duodenal Polyps in Familial Adenomatous Polyposis (FAP): o Confirmed FAP by genetic testing at first detection of colonic polyps or age 25 o High-risk for FAP (without genetic testing or with indeterminate results): i. First-degree relatives of FAP patients. OR ii. > 10 cumulative colorectal adenomas. OR o Colorectal adenomas with extracolonic FAP manifestations (e.g., duodenal/ampullary adenomas, desmoid tumors, thyroid carcinoma, retinal hamartomas, cysts, osteomas). o Screening is NOT MEDICALLY NECESSARY for categories i and ii above if genetic testing shows the absence of pathogenic APC gene variants.
• Gastric/Duodenal Polyps in MUTYH-associated Polyposis (MAP): o Begins at age 30–35 years for individuals with confirmed biallelic MUTYH mutations.

Surveillance of High-Risk Conditions • Esophageal Cancer: ▪ Barrett’s esophagus:

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▪ High-grade dysplasia: Every 3 months. ▪ Low-grade dysplasia: Yearly. ▪ No dysplasia: Every 3 years. ▪ Tylosis (Howel-Evans syndrome): Starting at age 30 (or earlier if family member developed cancer at a younger age), every 1-3 years. ▪ Severe esophageal injury from caustic ingestion: Starting 10-20 years post-ingestion, every 2-3 years. • Upper GI Polyps/Cancers in FAP and MAP: ▪ If the initial EGD is normal (no polyps or significant findings), repeat EGD every 4 years. ▪ If gastric or duodenal polyps are detected, surveillance intervals are adjusted based on the Spigelman classification for duodenal polyposis*, which assesses polyp number, size, histology, and dysplasia:
▪ Stage 0 (no polyps): EGD every 4 years. ▪ Stage I (mild polyposis): EGD every 2–3 years. ▪ Stage II: EGD every 1–3 years. ▪ Stage III: EGD every 6–12 months. ▪ Stage IV (severe polyposis): EGD every 3–6 months. ▪ For gastric fundic gland polyps, surveillance is typically aligned with duodenal findings. • Gastric Cancer ▪ Gastric intestinal metaplasia (GIM) with risk factors below should have repeat EGD every 3 years. ▪ Family history of gastric cancer in a first-degree relative ▪ Incomplete GIM ▪ Extensive or corpus GIM ▪ Racial/ethnic minorities in the United States (including African Americans, Hispanics, and Asians) ▪ First-generation immigrants from high-incidence areas (eg, Eastern Asia, mountainous Latin America)
• Gastric/Duodenal Cancer ▪ Lynch Syndrome: Every 2-4 years, starting at age 30. • Esophageal Varices in Cirrhosis o Cirrhosis with ongoing liver inflammation and no varices: every 2 years o Cirrhosis with NO active liver inflammation and no varices: every 3 years ▪ Compensated cirrhosis: ▪ platelet count >150,000/microL AND liver elastography <20 kPa: no surveillance needed ▪ platelet count <150,000/microL or liver elastography ≥20 kPa. ▪ Frequency of surveillance ▪ Ongoing liver inflammation and small varices without red signs: annual ▪ No active liver inflammation and small varices without red signs: every 2 years

*Spigelman classification for duodenal polyposis:

Saurin J, Gutknecht C, Napoleon B, et al. Surveillance of duodenal adenomas in familial adenomatous polyposis reveals high cumulative risk of advanced disease. J Clin Oncol 2004; 22:493

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Exclusions and Non-Indicated Uses The following conditions are considered INVESTIGATIONAL (NOT MEDICALLY NECESSARY), including, but not limited to: o EGD to rule out celiac disease in: ▪ Infertility. ▪ GI symptoms with negative serology and no malabsorption indicators. ▪ Osteoporosis without malabsorption evidence. o To evaluate radiographic findings of: ▪ Asymptomatic or uncomplicated sliding hiatal hernia. ▪ Uncomplicated duodenal ulcer responding to therapy. ▪ Deformed duodenal bulb without symptoms or responding to therapy. o Surveillance of healed benign disease (e.g., esophagitis, gastric/duodenal ulcer). o Surveillance during repeated dilations of benign strictures unless clinical status changes.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if a procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) Prior authorization is not required. Commercial PPO and Indemnity Prior authorization is not required. Medicare HMO BlueSM Prior authorization is not required. Medicare PPO BlueSM Prior authorization is not required.

CPT Codes / HCPCS Codes / ICD Codes
Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The above medical necessity criteria MUST be met for the following codes to be covered for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Codes CPT codes:

Code Description 43200 Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure) 43202 Esophagoscopy, flexible, transoral; with biopsy, single or multiple 43231 Esophagoscopy, flexible, transoral; with endoscopic ultrasound examination 43233 Esophagogastroduodenoscopy, flexible, transoral; with dilation of esophagus with balloon 30 mm diameter or larger) (includes fluoroscopic guidance, when performed) 43235 Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure)

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43237 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination limited to esophagus 43238 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound- guided intramural or transmural fine needle aspiration/biopsy(s), (included endoscopic ultrasound examination limited to esophagus) 43239 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) 43242 Esophagogastroduodenoscopy, flexible, transoral; with transendoscopic ultrasound- guided intramural or transmural fine needle aspiration/biopsy(s) (includes endoscopic ultrasound examination of the esophagus, stomach, and either the duodenum and/or jejunum as appropriate) 43259 Esophagogastroduodenoscopy, flexible, transoral; with endoscopic ultrasound examination, including the esophagus, stomach, and either the duodenum and/or jejunum as appropriate

The following ICD Diagnosis Codes are considered medically necessary when submitted with the CPT codes above if medical necessity criteria are met: ICD-10 Diagnosis Codes ICD-10-CM diagnosis codes: Code Description C12 Malignant Neoplasm of Pyriform Sinus C13.0 Malignant Neoplasm of Postcricoid Region C13.1 Malignant Neoplasm of Aryepiglottic Fold, Hypopharyngeal Aspect C13.2 Malignant Neoplasm of Posterior Wall of Hypopharynx C13.8 Malignant Neoplasm of Overlapping Sites of Hypopharynx C13.9 Malignant Neoplasm of Hypopharynx, Unspecified C15.3 Malignant Neoplasm of Upper Third of Esophagus C15.4 Malignant Neoplasm of Middle Third of Esophagus C15.5 Malignant Neoplasm of Lower Third of Esophagus C15.8 Malignant Neoplasm of Overlapping Sites of Esophagus C15.9 Malignant Neoplasm of Esophagus, Unspecified C16.0 Malignant Neoplasm of Cardia C16.1 Malignant Neoplasm of Fundus of Stomach C16.2 Malignant Neoplasm of Body of Stomach C16.3 Malignant Neoplasm of Pyloric Antrum C16.4 Malignant Neoplasm of Pylorus C16.5 Malignant Neoplasm of Lesser Curvature of Stomach, Unspecified C16.6 Malignant Neoplasm of Greater Curvature of Stomach, Unspecified C16.8 Malignant Neoplasm of Overlapping Sites of Stomach C16.9 Malignant Neoplasm of Stomach, Unspecified C17.0 Malignant Neoplasm of Duodenum C17.1 Malignant Neoplasm of Jejunum C17.2 Malignant Neoplasm of Ileum C17.3 Meckel's Diverticulum, Malignant C17.8 Malignant Neoplasm of Overlapping Sites of Small Intestine C17.9 Malignant Neoplasm of Small Intestine, Unspecified C18.0 Malignant neoplasm of cecum C18.1 Malignant neoplasm of appendix

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C18.2 Malignant neoplasm of ascending colon C18.4 Malignant neoplasm of transverse colon C18.6 Malignant neoplasm of descending colon C18.7 Malignant neoplasm of sigmoid colon C18.8 Malignant neoplasm of overlapping sites of colon C18.9 Malignant neoplasm of colon, unspecified C19 Malignant Neoplasm of Rectosigmoid Junction C20 Malignant neoplasm of rectum C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal C32.0 Malignant Neoplasm of Glottis C32.1 Malignant Neoplasm of Supraglottis C32.2 Malignant Neoplasm of Subglottis C32.3 Malignant Neoplasm of Laryngeal Cartilage C32.8 Malignant Neoplasm of Overlapping Sites of Larynx C32.9 Malignant Neoplasm of Larynx, Unspecified C33 Malignant Neoplasm of Trachea C78.5 Secondary malignant neoplasm of large intestine and rectum C78.80 Secondary malignant neoplasm of unspecified digestive organ C78.89 Secondary malignant neoplasm of other digestive organs C78.1 Secondary Malignant Neoplasm of Mediastinum C78.30 Secondary Malignant Neoplasm of Unspecified Respiratory organ C78.39 Secondary Malignant Neoplasm of Other Respiratory organs C78.4 Secondary Malignant Neoplasm of Small Intestine C81.01 Nodular Lymphocyte Predominant Hodgkin Lymphoma, Lymph Nodes of
Head, Face, and Neck C81.02 Nodular Lymphocyte Predominant Hodgkin Lymphoma, Intrathoracic
Lymph Nodes C81.03 Nodular Lymphocyte Predominant Hodgkin Lymphoma, Intra-Abdominal
Lymph Nodes C81.11 Nodular Sclerosis Hodgkin Lymphoma, Lymph Nodes of Head, Face, and
Neck C81.12 Nodular Sclerosis Hodgkin Lymphoma, Intrathoracic Lymph Nodes C81.13 Nodular Sclerosis Hodgkin Lymphoma, Intra-Abdominal Lymph Nodes C81.21 Mixed Cellularity Hodgkin Lymphoma, Lymph Nodes of Head, Face, and Neck C81.22 Mixed Cellularity Hodgkin Lymphoma, Intrathoracic Lymph Nodes C81.23 Mixed Cellularity Hodgkin Lymphoma, Intra-Abdominal Lymph Nodes C81.31 Lymphocyte Depleted Hodgkin Lymphoma, Lymph Nodes of Head, Face,
and Neck C81.32 Lymphocyte Depleted Hodgkin Lymphoma, Intrathoracic Lymph Nodes C81.33 Lymphocyte Depleted Hodgkin Lymphoma, Intra-Abdominal Lymph C81.41 Lymphocyte-Rich Hodgkin Lymphoma, Lymph Nodes of Head, Face, and Neck C81.42 Lymphocyte-Rich Hodgkin Lymphoma, Intrathoracic Lymph Nodes C81.43 Lymphocyte-Rich Hodgkin Lymphoma, Intra-Abdominal Lymph Nodes C81.71 Other Hodgkin Lymphoma, Lymph Nodes of Head, Face, and Neck C81.72 Other Hodgkin Lymphoma, Intrathoracic Lymph Nodes C81.73 Other Hodgkin Lymphoma, Intra-Abdominal Lymph Nodes C81.91 Hodgkin Lymphoma, Unspecified, Lymph Nodes of Head, Face, and Neck C81.92 Hodgkin Lymphoma, Unspecified, Intrathoracic Lymph Nodes C81.93 Hodgkin Lymphoma, Unspecified, Intra-Abdominal Lymph Nodes C82.01 Follicular Lymphoma Grade I, Lymph Nodes of Head, Face, and Neck C82.02 Follicular Lymphoma Grade I, Intrathoracic Lymph Nodes

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C82.03 Follicular Lymphoma Grade I, Intra-Abdominal Lymph Nodes C82.11 Follicular Lymphoma Grade II, Lymph Nodes of Head, Face, and Neck C82.12 Follicular Lymphoma Grade II, Intrathoracic Lymph Nodes C82.13 Follicular Lymphoma Grade II, Intra-Abdominal Lymph Nodes C82.21 Follicular Lymphoma Grade III, Unspecified, Lymph Nodes of Head, Face,
and Neck C82.22 Follicular Lymphoma Grade III, Unspecified, Intrathoracic Lymph Nodes C82.23 Follicular Lymphoma Grade III, Unspecified, Intra-Abdominal Lymph
Nodes C82.31 Follicular Lymphoma Grade III, Lymph Nodes of Head, Face, and Neck C82.32 Follicular Lymphoma Grade III, Intrathoracic Lymph Nodes C82.33 Follicular Lymphoma Grade III, Intra-Abdominal Lymph Nodes C82.51 Diffuse Follicle Center Lymphoma, Lymph Nodes of Head, Face, and
Neck C82.52 Diffuse Follicle Center Lymphoma, Intrathoracic Lymph Nodes C82.53 Diffuse Follicle Center Lymphoma, Intra-Abdominal Lymph Nodes C82.61 Cutaneous Follicle Center Lymphoma, Lymph Nodes of Head, Face, and
Neck C82.62 Cutaneous Follicle Center Lymphoma, Intrathoracic Lymph Nodes C82.63 Cutaneous Follicle Center Lymphoma, Intra-Abdominal Lymph Nodes C82.81 Other Types of Follicular Lymphoma, Lymph Nodes of Head, Face, and
Neck C82.82 Other Types of Follicular Lymphoma, Intrathoracic Lymph Nodes C82.83 Other Types of Follicular Lymphoma, Intra-Abdominal Lymph Nodes C82.91 Follicular Lymphoma, Unspecified, Lymph Nodes of Head, Face, and
Neck C82.92 Follicular Lymphoma, Unspecified, Intrathoracic Lymph Nodes C82.93 Follicular Lymphoma, Unspecified, Intra-Abdominal Lymph Nodes C83.01 Small Cell B-Cell Lymphoma, Lymph Nodes of Head, Face, and Neck C83.02 Small Cell B-Cell Lymphoma, Intrathoracic Lymph Nodes C83.03 Small Cell B-Cell Lymphoma, Intra-Abdominal Lymph Nodes C83.11 Mantle Cell Lymphoma, Lymph Nodes of Head, Face, and Neck C83.12 Mantle Cell Lymphoma, Intrathoracic Lymph Nodes C83.13 Mantle Cell Lymphoma, Intra-Abdominal Lymph Nodes C83.31 Diffuse Large B-Cell Lymphoma, Lymph Nodes of Head, Face, and Neck C83.32 Diffuse Large B-Cell Lymphoma, Intrathoracic Lymph Nodes C83.33 Diffuse Large B-Cell Lymphoma, Intra-Abdominal Lymph Nodes C83.51 Lymphoblastic (Diffuse) Lymphoma, Lymph Nodes of Head, Face, and
Neck C83.52 Lymphoblastic (Diffuse) Lymphoma, Intrathoracic Lymph Nodes C83.53 Lymphoblastic (Diffuse) Lymphoma, Intra-Abdominal Lymph Nodes C83.71 Burkitt Lymphoma, Lymph Nodes of Head, Face, and Neck C83.72 Burkitt Lymphoma, Intrathoracic Lymph Nodes C83.73 Burkitt Lymphoma, Intra-Abdominal Lymph Nodes C83.81 Other Non-Follicular Lymphoma, Lymph Nodes of Head, Face, and Neck C83.82 Other Non-Follicular Lymphoma, Intrathoracic Lymph Nodes C83.83 Other Non-Follicular Lymphoma, Intra-Abdominal Lymph Nodes C83.91 Non-Follicular (Diffuse) Lymphoma, Unspecified, Lymph Nodes of Head,
Face, and Neck C83.92 Non-Follicular (Diffuse) Lymphoma, Unspecified, Intrathoracic Lymph
Nodes 83.93 Non-Follicular (Diffuse) Lymphoma, Unspecified, Intra-Abdominal Lymph

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Nodes C84.01 Mycosis Fungoides, Lymph Nodes of Head, Face, and Neck C84.02 Mycosis Fungoides, Intrathoracic Lymph Nodes C84.03 Mycosis Fungoides, Intra-Abdominal Lymph Nodes C84.11 Sezary Disease, Lymph Nodes of Head, Face, and Neck C84.12 Sezary Disease, Intrathoracic Lymph Nodes C84.13 Sezary Disease, Intra-Abdominal Lymph Nodes C84.41 Peripheral T-Cell Lymphoma, Not Classified, Lymph Nodes of Head, Face,
and Neck C84.42 Peripheral T-Cell Lymphoma, Not Classified, Intrathoracic Lymph Nodes C84.43 Peripheral T-Cell Lymphoma, Not Classified, Intra-Abdominal Lymph
Nodes C84.61 Anaplastic Large Cell Lymphoma, Alk-Positive, Lymph Nodes of Head,
Face, and Neck C84.62 Anaplastic Large Cell Lymphoma, Alk-Positive, Intrathoracic Lymph
Nodes C84.63 Anaplastic Large Cell Lymphoma, Alk-Positive, Intra-Abdominal Lymph
Nodes C84.71 Anaplastic Large Cell Lymphoma, Alk-Negative, Lymph Nodes of Head,
Face, and Neck C84.72 Anaplastic Large Cell Lymphoma, Alk-Negative, Intrathoracic Lymph
Nodes C84.73 Anaplastic Large Cell Lymphoma, Alk-Negative, Intra-Abdominal Lymph
Nodes C84.91 Mature T/Nk-Cell Lymphomas, Unspecified, Lymph Nodes of Head, Face,
and Neck C84.92 Mature T/Nk-Cell Lymphomas, Unspecified, Intrathoracic Lymph Nodes C84.93 Mature T/Nk-Cell Lymphomas, Unspecified, Intra-Abdominal Lymph C84.A1 Cutaneous T-Cell Lymphoma, Unspecified Lymph Nodes of Head, Face,
and Neck C84.A2 Cutaneous T-Cell Lymphoma, Unspecified, Intrathoracic Lymph Nodes C84.A3 Cutaneous T-Cell Lymphoma, Unspecified, Intra-Abdominal Lymph
Nodes C84.Z1 Other Mature T/Nk-Cell Lymphomas, Lymph Nodes of Head, Face, and
Neck C84.Z2 Other Mature T/Nk-Cell Lymphomas, Intrathoracic Lymph Nodes C84.Z3 Other Mature T/Nk-Cell Lymphomas, Intra-Abdominal Lymph Nodes C85.11 Unspecified B-Cell Lymphoma, Lymph Nodes of Head, Face, and Neck C85.12 Unspecified B-Cell Lymphoma, Intrathoracic Lymph Nodes C85.13 Unspecified B-Cell Lymphoma, Intra-Abdominal Lymph Nodes C85.21
Mediastinal (Thymic) Large B-Cell Lymphoma, Lymph Nodes of Head,
Face, and Neck
C85.22
Mediastinal (Thymic) Large B-Cell Lymphoma, Intrathoracic Lymph
Nodes
C85.23
Mediastinal (Thymic) Large B-Cell Lymphoma, Intra-Abdominal Lymph
Nodes
C85.81
Other Specified Types of Non-Hodgkin Lymphoma, Lymph Nodes of
Head, Face, and Neck
C85.82
Other Specified Types of Non-Hodgkin Lymphoma, Intrathoracic Lymph
Nodes
C85.83
Other Specified Types of Non-Hodgkin Lymphoma, Intra-Abdominal
Lymph Nodes
C85.91
Non-Hodgkin Lymphoma, Unspecified, Lymph Nodes of Head, Face, and

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Neck
C85.92
Non-Hodgkin Lymphoma, Unspecified, Intrathoracic Lymph Nodes
C85.93
Non-Hodgkin Lymphoma, Unspecified, Intra-Abdominal Lymph Nodes
C86.0
Extranodal Nk/T-Cell Lymphoma, Nasal Type
C86.2
Enteropathy-Type (Intestinal) T-Cell Lymphoma
C86.3
Subcutaneous Panniculitis-Like T-Cell Lymphoma
C86.4
Blastic Nk-Cell Lymphoma
C88.4
Extranodal Marginal Zone B-Cell Lymphoma of Mucosa-Associated
Lymphoid Tissue [Malt-Lymphoma]
C91.40
Hairy Cell Leukemia Not Having Achieved Remission
C91.41
Hairy Cell Leukemia, In Remission
C91.42
Hairy Cell Leukemia, In Relapse
C96.0
Multifocal and Multisystemic (Disseminated) Langerhans-Cell
Histiocytosis
C96.2
Malignant mast cell tumor [confirmation and specific histological
diagnosis of radiologically demonstrated lesions]
C96.20
Malignant mast cell neoplasm, unspecified
C96.21
Aggressive systemic mastocytosis
C96.22
Mast cell sarcoma
C96.29
Other malignant mast cell neoplasm
C96.9
Malignant Neoplasm of Lymphoid, Hematopoietic and Related Tissue,
Unspecified
C96.A
Histiocytic Sarcoma
C96.Z
Other Specified Malignant Neoplasms of Lymphoid, Hematopoietic and
Related Tissue
D00.1
Carcinoma In Situ of Esophagus
D12.0
Benign Neoplasm of Cecum
D12.1
Benign Neoplasm of Appendix
D12.2
Benign Neoplasm of Ascending Colon
D12.3
Benign Neoplasm of Transverse Colon
D12.4
Benign Neoplasm of Descending Colon
D12.5
Benign Neoplasm of Sigmoid Colon
D12.6
Benign Neoplasm of Colon, Unspecified
D13.0
Benign Neoplasm of Esophagus
D13.1
Benign Neoplasm of Stomach
D13.2
Benign Neoplasm of Duodenum
D13.30
Benign Neoplasm of Unspecified Part of Small Intestine
D13.39
Benign Neoplasm of Other Parts of Small Intestine
D13.91 Familial adenomatous polyposis D37.8
Neoplasm of Uncertain Behavior of Other Specified Digestive organs
D37.9
Neoplasm of Uncertain Behavior of Digestive organ, Unspecified
D50.0
Iron Deficiency Anemia Secondary To Blood Loss (Chronic)
D50.1
Sideropenic Dysphagia
D50.8
Other Iron Deficiency Anemias
D50.9
Iron Deficiency Anemia, Unspecified
D51.0
Vitamin B12 Deficiency Anemia Due To Intrinsic Factor Deficiency
D62.0
Acute Posthemorrhagic Anemia
D89.810
Acute Graft-Versus-Host Disease
D89.811
Chronic Graft-Versus-Host Disease
D89.812
Acute On Chronic Graft-Versus-Host Disease
D89.813
Graft-Versus-Host Disease, Unspecified

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E61.1 Iron deficiency I69.091
Dysphagia Following Nontraumatic Subarachnoid Hemorrhage
I69.191
Dysphagia Following Nontraumatic Intracerebral Hemorrhage
I69.291
Dysphagia Following Other Nontraumatic Intracranial Hemorrhage
I69.391
Dysphagia Following Cerebral Infarction
I69.891
Dysphagia Following Other Cerebrovascular Disease
I69.991
Dysphagia Following Unspecified Cerebrovascular Disease
I85.00
Esophageal Varices without Bleeding
I85.01
Esophageal Varices with Bleeding
I85.10
Secondary Esophageal Varices without Bleeding
I85.11
Secondary Esophageal Varices with Bleeding
I86.4 Gastric varices J86.0
Pyothorax with Fistula
K20.0
Eosinophilic Esophagitis
K20.80
Other esophagitis without bleeding
K20.81
Other esophagitis with bleeding
K20.90
Esophagitis, unspecified without bleeding
K20.91
Esophagitis, unspecified with bleeding
K21.00
Gastro-esophageal reflux disease with esophagitis, without bleeding
K21.01
Gastro-esophageal reflux disease with esophagitis, with bleeding
K21.9
Gastro-esophageal reflux disease without esophagitis
K22.0
Achalasia of Cardia
K22.10
Ulcer of Esophagus without Bleeding
K22.11
Ulcer of Esophagus with Bleeding
K22.2
Esophageal Obstruction
K22.3
Perforation of Esophagus
K22.4
Dyskinesia of Esophagus
K22.5
Diverticulum of Esophagus, Acquired
K22.6
Gastro-Esophageal Laceration-Hemorrhage Syndrome
K22.70
Barrett's Esophagus without Dysplasia
K22.710
Barrett's Esophagus with Low Grade Dysplasia
K22.711
Barrett's Esophagus with High Grade Dysplasia
K22.719
Barrett's Esophagus with Dysplasia, Unspecified
K22.89
Other Specified Diseases of Esophagus
K25.0
Acute Gastric Ulcer with Hemorrhage
K25.1
Acute Gastric Ulcer with Perforation
K25.2
Acute Gastric Ulcer with Both Hemorrhage and Perforation
K25.3
Acute Gastric Ulcer without Hemorrhage or Perforation
K25.4
Chronic or Unspecified Gastric Ulcer with Hemorrhage
K25.5
Chronic or Unspecified Gastric Ulcer with Perforation
K25.6
Chronic or Unspecified Gastric Ulcer with Both Hemorrhage and
Perforation
K25.7
Chronic Gastric Ulcer without Hemorrhage or Perforation
K25.9
Gastric Ulcer, Unspecified as Acute or Chronic, without Hemorrhage or
Perforation
K26.0
Acute Duodenal Ulcer with Hemorrhage
K26.1
Acute Duodenal Ulcer with Perforation
K26.2
Acute Duodenal Ulcer with Both Hemorrhage and Perforation
K26.3
Acute Duodenal Ulcer without Hemorrhage or Perforation
K26.4
Chronic or Unspecified Duodenal Ulcer with Hemorrhage
K26.5
Chronic or Unspecified Duodenal Ulcer with Perforation

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K26.6
Chronic or Unspecified Duodenal Ulcer with Both Hemorrhage and
Perforation
K26.7
Chronic Duodenal Ulcer without Hemorrhage or Perforation
K26.9
Duodenal Ulcer, Unspecified as Acute or Chronic, without Hemorrhage
or Perforation
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
K28.0
Acute Gastrojejunal Ulcer with Hemorrhage
K28.1
Acute Gastrojejunal Ulcer with Perforation
K28.2
Acute Gastrojejunal Ulcer with Both Hemorrhage and Perforation
K28.3
Acute Gastrojejunal Ulcer without Hemorrhage or Perforation
K28.4
Chronic or Unspecified Gastrojejunal Ulcer with Hemorrhage
K28.5
Chronic or Unspecified Gastrojejunal Ulcer with Perforation
K28.6
Chronic or Unspecified Gastrojejunal Ulcer with Both Hemorrhage and
Perforation
K28.7
Chronic Gastrojejunal Ulcer without Hemorrhage or Perforation
K28.9
Gastrojejunal Ulcer, Unspecified as Acute or Chronic, without
Hemorrhage or Perforation
K29.00
Acute Gastritis without Bleeding
K29.01
Acute Gastritis with Bleeding
K29.20
Alcoholic Gastritis without Bleeding
K29.21
Alcoholic Gastritis with Bleeding
K29.30
Chronic Superficial Gastritis without Bleeding
K29.31
Chronic Superficial Gastritis with Bleeding
K29.40
Chronic Atrophic Gastritis without Bleeding
K29.41
Chronic Atrophic Gastritis with Bleeding
K29.50
Unspecified Chronic Gastritis without Bleeding
K29.51
Unspecified Chronic Gastritis with Bleeding
K29.60
Other Gastritis without Bleeding
K29.61
Other Gastritis with Bleeding
K29.70
Gastritis, Unspecified, without Bleeding
K29.71
Gastritis, Unspecified, with Bleeding
K29.80
Duodenitis without Bleeding
K29.81
Duodenitis with Bleeding
K29.90
Gastroduodenitis, Unspecified, without Bleeding
K29.91
Gastroduodenitis, Unspecified, with Bleeding
K30 Functional Dyspepsia
K31.0 Acute dilatation of stomach K31.1 Adult hypertrophic pyloric stenosis K31.2 Hourglass stricture and stenosis of stomach K31.3 Pylorospasm, not elsewhere classified

12

K31.4 Gastric diverticulum K31.5 Obstruction of duodenum K31.6 Fistula of stomach and duodenum K31.7
Polyp of Stomach and Duodenum
K31.811 Angiodysplasia of stomach and duodenum with bleeding K31.819 Angiodysplasia of stomach and duodenum without bleeding K31.82 Dieulafoy lesion (hemorrhagic) of stomach and duodenum K31.83 Achlorhydria K31.84 Gastroparesis K31.89 Other diseases of stomach and duodenum K31.9 Disease of stomach and duodenum, unspecified K31.A0 Gastric intestinal metaplasia, unspecified K31.A11 Gastric intestinal metaplasia without dysplasia, involving the antrum K31.A12 Gastric intestinal metaplasia without dysplasia, involving the body (corpus) K31.A13 Gastric intestinal metaplasia without dysplasia, involving the fundus K31.A14 Gastric intestinal metaplasia without dysplasia, involving the cardia K31.A15 Gastric intestinal metaplasia without dysplasia, involving multiple sites K31.A19 Gastric intestinal metaplasia without dysplasia, unspecified site K31.A21 Gastric intestinal metaplasia with low grade dysplasia K31.A22 Gastric intestinal metaplasia with high grade dysplasia K31.A29 Gastric intestinal metaplasia with dysplasia, unspecified K44.0
Diaphragmatic Hernia with Obstruction, without Gangrene
K50.00
Crohn's Disease of Small Intestine without Complications
K50.011
Crohn's Disease of Small Intestine with Rectal Bleeding
K50.012
Crohn's Disease of Small Intestine with Intestinal Obstruction
K50.013
Crohn's Disease of Small Intestine with Fistula
K50.014
Crohn's Disease of Small Intestine with Abscess
K50.018
Crohn's Disease of Small Intestine with Other Complication
K50.019
Crohn's Disease of Small Intestine with Unspecified Complications
K50.11
Crohn's disease of large intestine with complications
K50.111
Crohn's disease of large intestine with rectal bleeding
K50.112
Crohn's disease of large intestine with intestinal obstruction
K50.113
Crohn's disease of large intestine with fistula
K50.114
Crohn's disease of large intestine with abscess
K50.118
Crohn's disease of large intestine with other complication
K50.119
Crohn's disease of large intestine with unspecified complications
K50.8
Crohn's disease of both small and large intestine
K50.80
Crohn's disease of both small and large intestine without complications
K50.81
Crohn's disease of both small and large intestine with complications
K50.811
Crohn's disease of both small and large intestine with rectal bleeding
K50.812
Crohn's disease of both small and large intestine with intestinal
obstruction
K50.813
Crohn's disease of both small and large intestine with fistula
K50.814
Crohn's disease of both small and large intestine with abscess
K50.818
Crohn's disease of both small and large intestine with other complication
K50.819
Crohn's disease of both small and large intestine with unspecified complications
K50.9
Crohn's disease, unspecified
K50.90
Crohn's disease, unspecified, without complications
K50.91
Crohn's disease, unspecified, with complications
K50.911
Crohn's disease, unspecified, with rectal bleeding
K50.912
Crohn's disease, unspecified, with intestinal obstruction

13

K50.913
Crohn's disease, unspecified, with fistula
K50.914
Crohn's disease, unspecified, with abscess
K50.918
Crohn's disease, unspecified, with other complication
K50.919
Crohn's disease, unspecified, with unspecified complications
K51.00
Ulcerative (Chronic) Pancolitis without Complications
K51.011
Ulcerative (Chronic) Pancolitis with Rectal Bleeding
K51.012
Ulcerative (Chronic) Pancolitis with Intestinal Obstruction
K51.013
Ulcerative (Chronic) Pancolitis with Fistula
K51.014
Ulcerative (Chronic) Pancolitis with Abscess
K51.018
Ulcerative (Chronic) Pancolitis with Other Complication
K51.019
Ulcerative (Chronic) Pancolitis with Unspecified Complications
K52.0 Gastroenteritis and colitis due to radiation K52.1 Toxic gastroenteritis and colitis K52.21 Food protein-induced enterocolitis syndrome K52.22 Food protein-induced enteropathy K52.29 Other allergic and dietetic gastroenteritis and colitis K52.81 Eosinophilic gastritis or gastroenteritis K52.89 Other specified noninfective gastroenteritis and colitis K52.9 Noninfective gastroenteritis and colitis, unspecified K58.0
Irritable Bowel Syndrome with Diarrhea
K58.1
Irritable Bowel Syndrome with Constipation
K58.2
Mixed Irritable Bowel Syndrome
K58.8
Other Irritable Bowel Syndrome
K58.9
Irritable Bowel Syndrome without Diarrhea
K63.5
Polyp of Colon
K70.2
Alcoholic Fibrosis and Sclerosis of Liver
K70.30
Alcoholic Cirrhosis of Liver without Ascites
K70.31
Alcoholic Cirrhosis of Liver with Ascites
K71.7 Toxic liver disease with fibrosis and cirrhosis of liver K74.00
Hepatic fibrosis, unspecified
K74.01
Hepatic fibrosis, early fibrosis
K74.02
Hepatic fibrosis, advanced fibrosis
K74.3
Primary Biliary Cirrhosis
K74.4
Secondary Biliary Cirrhosis
K74.5
Biliary Cirrhosis, Unspecified
K74.60
Unspecified Cirrhosis of Liver
K74.69
Other Cirrhosis of Liver
K76.6
Portal Hypertension
K86.2
Cyst of pancreas
K90.0
Celiac disease
K92.0
Hematemesis
K92.1
Melena
K92.2
Gastrointestinal Hemorrhage, Unspecified
K94.30
Esophagostomy Complications, Unspecified
K94.31
Esophagostomy Hemorrhage
K94.33
Esophagostomy Infection
K94.39
Esophagostomy Malfunction
Q26.5
Other Complications of Esophagostomy
Q26.6
Portal Vein-Hepatic Artery Fistula
Q27.33
Arteriovenous Malformation of Digestive System Vessel
Q27.8
Other Specified Congenital Malformations of Peripheral Vascular System

14

Q39.0
Atresia of Esophagus without Fistula
Q39.1
Atresia of Esophagus with Tracheo-Esophageal Fistula
Q39.2
Congenital Tracheo-Esophageal Fistula without Atresia
Q39.3
Congenital Stenosis and Stricture of Esophagus
Q39.4
Esophageal Web
Q39.5
Congenital Dilatation of Esophagus
Q39.6
Congenital Diverticulum of Esophagus
Q39.8
Other Congenital Malformations of Esophagus
Q39.9
Congenital Malformation of Esophagus, Unspecified
Q40.2
Other Specified Congenital Malformations of Stomach
Q40.3
Congenital Malformation of Stomach, Unspecified
Q43.5
Ectopic anus
Q43.6
Congenital fistula of rectum and anus
Q43.7
Persistent cloaca
Q43.8
Other specified congenital malformations of intestine
Q43.9
Congenital malformation of intestine, unspecified
Q82.8 Other specified congenital malformations of skin R10.0
Acute abdomen
R10.10
Upper abdominal pain, unspecified
R10.11
Right Upper Quadrant Pain
R10.12
Left Upper Quadrant Pain
R10.13
Epigastric pain
R10.30 Lower abdominal pain, unspecified R10.31
Right lower quadrant pain
R10.32
Left lower quadrant pain
R10.33
Periumbilical pain
R10.84 Generalized abdominal pain R11.0
Nausea with vomiting
R11.10
Vomiting, unspecified
R11.11
Vomiting without nausea
R11.12
Projectile vomiting
R11.13
Vomiting of fecal matter
R11.14
Bilious vomiting
R11.2
Nausea with vomiting, unspecified
R13.10
Dysphagia, Unspecified
R13.11
Dysphagia, oral Phase
R13.12
Dysphagia, oropharyngeal Phase
R13.13
Dysphagia, Pharyngeal Phase
R13.14
Dysphagia, Pharyngoesophageal Phase
R13.19
Other Dysphagia
R63.4 Abnormal weight loss R93.3
Abnormal Findings on Diagnostic Imaging of Other Parts of Digestive Tract
R93.5
Abnormal Findings on Diagnostic Imaging of Other Abdominal Regions, Including Retroperitoneum
S21.301A
Unspecified Open Wound of Right Front Wall of Thorax with Penetration into Thoracic Cavity, Initial Encounter
S21.301D
Unspecified Open Wound of Right Front Wall of Thorax with Penetration into Thoracic Cavity, Subsequent Encounter
S21.301S
Unspecified Open Wound of Right Front Wall of Thorax with Penetration into Thoracic Cavity, Sequela

15

S21.302A
Unspecified Open Wound of Left Front Wall of Thorax with Penetration Into Thoracic Cavity, Initial Encounter
S21.302D
Unspecified Open Wound of Left Front Wall of Thorax with Penetration into Thoracic Cavity, Subsequent Encounter
S21.302S
Unspecified Open Wound of Left Front Wall of Thorax with Penetration Into Thoracic Cavity, Sequela
S21.309A
Unspecified Open Wound of Unspecified Front Wall of Thorax with Penetration Into Thoracic Cavity, Initial Encounter
S21.309D
Unspecified Open Wound of Unspecified Front Wall of Thorax with Penetration Into Thoracic Cavity, Subsequent Encounter
S21.309S
Unspecified Open Wound of Unspecified Front Wall of Thorax with Penetration Into Thoracic Cavity, Sequela
S27.812A
Contusion of Esophagus (Thoracic Part), Initial Encounter
S27.812D
Contusion of Esophagus (Thoracic Part), Subsequent Encounter
S27.812S
Contusion of Esophagus (Thoracic Part), Sequela
S27.813A
Laceration of Esophagus (Thoracic Part), Initial Encounter
S27.813D
Laceration of Esophagus (Thoracic Part), Subsequent Encounter
S27.813S
Laceration of Esophagus (Thoracic Part), Sequela
S27.818A
Other Injury of Esophagus (Thoracic Part), Initial Encounter
S27.818D
Other Injury of Esophagus (Thoracic Part), Subsequent Encounter
S27.818S
Other Injury of Esophagus (Thoracic Part), Sequela
S27.819A
Unspecified Injury of Esophagus (Thoracic Part), Initial Encounter
S27.819D
Unspecified Injury of Esophagus (Thoracic Part), Subsequent Encounter
S27.819S
Unspecified Injury of Esophagus (Thoracic Part), Sequela
T18.100A
Unspecified Foreign Body in Esophagus Causing Compression of Trachea, Initial Encounter
T18.100D
Unspecified Foreign Body in Esophagus Causing Compression of Trachea, Subsequent Encounter
T18.100S
Unspecified Foreign Body in Esophagus Causing Compression of Trachea, Sequela
T18.108A
Unspecified Foreign Body in Esophagus Causing Other Injury, Initial Encounter
T18.108D
Unspecified Foreign Body in Esophagus Causing Other Injury, Subsequent Encounter
T18.108S
Unspecified Foreign Body in Esophagus Causing Other Injury, Sequela
T18.110A
Gastric Contents in Esophagus Causing Compression of Trachea, Initial Encounter
T18.110D
Gastric Contents in Esophagus Causing Compression of Trachea, Subsequent Encounter
T18.110S
Gastric Contents in Esophagus Causing Compression of Trachea, Sequela
T18.118A
Gastric Contents in Esophagus Causing Other Injury, Initial Encounter
T18.118D
Gastric Contents in Esophagus Causing Other Injury, Subsequent Encounter
T18.118S
Gastric Contents in Esophagus Causing Other Injury, Sequela
T18.120A
Food In Esophagus Causing Compression of Trachea, Initial Encounter
T18.120D
Food In Esophagus Causing Compression of Trachea, Subsequent Encounter
T18.120S
Food In Esophagus Causing Compression of Trachea, Sequela
T18.128A
Food In Esophagus Causing Other Injury, Initial Encounter
T18.128D
Food In Esophagus Causing Other Injury, Subsequent Encounter
T18.128S
Food In Esophagus Causing Other Injury, Sequela
T18.190A
Other Foreign Object in Esophagus Causing Compression of Trachea, Initial Encounter
T18.190D
Other Foreign Object in Esophagus Causing Compression of Trachea, Subsequent Encounter
T18.190S
Other Foreign Object in Esophagus Causing Compression of Trachea, Sequela
T18.198A
Other Foreign Object in Esophagus Causing Other Injury, Initial Encounter
T18.198D
Other Foreign Object in Esophagus Causing Other Injury, Subsequent Encounter
T18.198S
Other Foreign Object in Esophagus Causing Other Injury, Sequela

16

T18.2XXA
Foreign Body in Stomach, Initial Encounter
T18.2XXD
Foreign Body in Stomach, Subsequent Encounter
T18.2XXS
Foreign Body in Stomach, Sequela
T18.8XXA
Foreign Body in Other Parts of Alimentary Tract, Initial Encounter
T18.8XXD
Foreign Body in Other Parts of Alimentary Tract, Subsequent Encounter
T18.8XXS
Foreign Body in Other Parts of Alimentary Tract, Sequela
T18.9XXA
Foreign Body of Alimentary Tract, Part Unspecified, Initial Encounter
T18.9XXD
Foreign Body of Alimentary Tract, Part Unspecified, Subsequent Encounter
T18.9XXS
Foreign Body of Alimentary Tract, Part Unspecified, Sequela
T28.1XXA
Burn of Esophagus, Initial Encounter
T28.1XXD
Burn of Esophagus, Subsequent Encounter
T28.1XXS
Burn of Esophagus, Sequela
T28.6XXA
Corrosion of Esophagus, Initial Encounter
T28.6XXD
Corrosion of Esophagus, Subsequent Encounter
T28.6XXS
Corrosion of Esophagus, Sequela
T54.0X1A
Toxic Effect of Phenol and Phenol Homologues, Accidental (Unintentional), Initial Encounter
T54.0X1D
Toxic Effect of Phenol and Phenol Homologues, Accidental (Unintentional), Subsequent Encounter
T54.0X1S
Toxic Effect of Phenol and Phenol Homologues, Accidental (Unintentional), Sequela
T54.0X2A
Toxic Effect of Phenol and Phenol Homologues, Intentional Self-Harm, Initial Encounter
T54.0X2D
Toxic Effect of Phenol and Phenol Homologues, Intentional Self-Harm, Subsequent Encounter
T54.0X2S
Toxic Effect of Phenol and Phenol Homologues, Intentional Self-Harm, Sequela
T54.0X3A
Toxic Effect of Phenol and Phenol Homologues, Assault, Initial Encounter
T54.0X3D
Toxic Effect of Phenol and Phenol Homologues, Assault, Subsequent
Encounter
T54.0X3S
Toxic Effect of Phenol and Phenol Homologues, Assault, Sequela
T54.0X4A
Toxic Effect of Phenol and Phenol Homologues, Undetermined, Initial Encounter
T54.0X4D
Toxic Effect of Phenol and Phenol Homologues, Undetermined, Subsequent Encounter
T54.0X4S
Toxic Effect of Phenol and Phenol Homologues, Undetermined, Sequela
T54.1X1A
Toxic Effect of Other Corrosive organic Compounds, Accidental (Unintentional), Initial Encounter
T54.1X1D
Toxic Effect of Other Corrosive organic Compounds, Accidental (Unintentional), Subsequent Encounter
T54.1X1S
Toxic Effect of Other Corrosive organic Compounds, Accidental (Unintentional), Sequela
T54.1X2A
Toxic Effect of Other Corrosive organic Compounds, Intentional Self- Harm, Initial Encounter
T54.1X2D
Toxic Effect of Other Corrosive organic Compounds, Intentional Self- Harm, Subsequent Encounter
T54.1X2S
Toxic Effect of Other Corrosive organic Compounds, Intentional Self- Harm, Sequela
T54.1X3A
Toxic Effect of Other Corrosive organic Compounds, Assault, Initial Encounter
T54.1X3D
Toxic Effect of Other Corrosive organic Compounds, Assault, Subsequent Encounter
T54.1X3S
Toxic Effect of Other Corrosive organic Compounds, Assault, Sequela
T54.1X4A
Toxic Effect of Other Corrosive organic Compounds, Undetermined, Initial Encounter
T54.1X4D
Toxic Effect of Other Corrosive organic Compounds, Undetermined, Subsequent Encounter
T54.1X4S
Toxic Effect of Other Corrosive organic Compounds, Undetermined, Sequela
T54.2X1A
Toxic Effect of Corrosive Acids and Acid-Like Substances, Accidental (Unintentional), Initial Encounter
T54.2X1D
Toxic Effect of Corrosive Acids and Acid-Like Substances, Accidental (Unintentional), Subsequent Encounter

17

T54.2X1S
Toxic Effect of Corrosive Acids and Acid-Like Substances, Accidental (Unintentional), Sequela
T54.2X2A
Toxic Effect of Corrosive Acids and Acid-Like Substances, Intentional Self- Harm, Initial Encounter
T54.2X2D
Toxic Effect of Corrosive Acids and Acid-Like Substances, Intentional Self- Harm, Subsequent Encounter
T54.2X2S
Toxic Effect of Corrosive Acids and Acid-Like Substances, Intentional Self- Harm, Sequela
T54.2X3A
Toxic Effect of Corrosive Acids and Acid-Like Substances, Assault, Initial Encounter
T54.2X3D
Toxic Effect of Corrosive Acids and Acid-Like Substances, Assault, Subsequent Encounter
T54.2X3S
Toxic Effect of Corrosive Acids and Acid-Like Substances, Assault, Sequela
T54.2X4A
Toxic Effect of Corrosive Acids and Acid-Like Substances, Undetermined, Initial Encounter
T54.2X4D
Toxic Effect of Corrosive Acids and Acid-Like Substances, Undetermined, Subsequent Encounter
T54.2X4S
Toxic Effect of Corrosive Acids and Acid-Like Substances, Undetermined, Sequela
T54.3X1A
Toxic Effect of Corrosive Alkalis and Alkali-Like Substances, Accidental (Unintentional), Initial Encounter
T54.3X1D
Toxic Effect of Corrosive Alkalis and Alkali-Like Substances, Accidental (Unintentional), Subsequent Encounter
T54.3X1S
Toxic Effect of Corrosive Alkalis and Alkali-Like Substances, Accidental (Unintentional), Sequela
T54.3X2A
Toxic Effect of Corrosive Alkalis and Alkali-Like Substances, Intentional Self-Harm, Initial Encounter
T54.3X2D
Toxic Effect of Corrosive Alkalis and Alkali-Like Substances, Intentional Self-Harm, Subsequent Encounter
T54.3X2S
Toxic Effect of Corrosive Alkalis and Alkali-Like Substances, Intentional Self-Harm, Sequela
T54.3X3A
Toxic Effect of Corrosive Alkalis and Alkali-Like Substances, Assault, Initial Encounter
T54.3X3D
Toxic Effect of Corrosive Alkalis and Alkali-Like Substances, Assault, Subsequent Encounter
T54.3X3S
Toxic Effect of Corrosive Alkalis and Alkali-Like Substances, Assault, Sequela
T54.3X4A
Toxic Effect of Corrosive Alkalis and Alkali-Like Substances, Undetermined, Initial Encounter
T54.3X4D
Toxic Effect of Corrosive Alkalis and Alkali-Like Substances, Undetermined, Subsequent Encounter
T54.3X4S
Toxic Effect of Corrosive Alkalis and Alkali-Like Substances, Undetermined, Sequela
T54.91XA
Toxic Effect of Unspecified Corrosive Substance, Accidental (Unintentional), Initial Encounter
T54.91XD
Toxic Effect of Unspecified Corrosive Substance, Accidental (Unintentional), Subsequent Encounter
T54.91XS
Toxic Effect of Unspecified Corrosive Substance, Accidental (Unintentional), Sequela
T54.92XA
Toxic Effect of Unspecified Corrosive Substance, Intentional Self-Harm, Initial Encounter
T54.92XD
Toxic Effect of Unspecified Corrosive Substance, Intentional Self-Harm, Subsequent Encounter
T54.92xS
Toxic Effect of Unspecified Corrosive Substance, Intentional Self-Harm, Sequela
T54.93xA
Toxic Effect of Unspecified Corrosive Substance, Assault, Initial Encounter
T54.93XD
Toxic Effect of Unspecified Corrosive Substance, Assault, Subsequent Encounter
T54.93XS
Toxic Effect of Unspecified Corrosive Substance, Assault, Sequela
T54.94xA
Toxic Effect of Unspecified Corrosive Substance, Undetermined, Initial Encounter
T54.94XD
Toxic Effect of Unspecified Corrosive Substance, Undetermined, Subsequent Encounter
T54.94xS
Toxic Effect of Unspecified Corrosive Substance, Undetermined, Sequela

18

T57.1X1A
Toxic Effect of Phosphorus and Its Compounds, Accidental (Unintentional), Initial Encounter
T57.1X1D
Toxic Effect of Phosphorus and Its Compounds, Accidental (Unintentional), Subsequent Encounter
T57.1X1S
Toxic Effect of Phosphorus and Its Compounds, Accidental (Unintentional), Sequela
T57.1X2A
Toxic Effect of Phosphorus and Its Compounds, Intentional Self-Harm, Initial Encounter
T57.1X2D
Toxic Effect of Phosphorus and Its Compounds, Intentional Self-Harm, Subsequent Encounter
T57.1X2S
Toxic Effect of Phosphorus and Its Compounds, Intentional Self-Harm, Sequela
T57.1X3A
Toxic Effect of Phosphorus and Its Compounds, Assault, Initial Encounter
T57.1X3D
Toxic Effect of Phosphorus and Its Compounds, Assault, Subsequent Encounter
T57.1X3S
Toxic Effect of Phosphorus and Its Compounds, Assault, Sequela
T57.1X4A
Toxic Effect of Phosphorus and Its Compounds, Undetermined, Initial
Encounter
T57.1X4D
Toxic Effect of Phosphorus and Its Compounds, Undetermined, Subsequent Encounter
T57.1X4S
Toxic Effect of Phosphorus and Its Compounds, Undetermined, Sequela
Z15.09
Genetic Susceptibility to Other Malignant Neoplasm
Z83.72 Family history of familial adenomatous polyposis Z85.020
Personal History of Malignant Carcinoid Tumor of Stomach
Z85.028
Personal History of Other Malignant Neoplasm of Stomach
Z86.0100 Personal history of colon polyps, unspecified Z86.0101 Personal history of adenomatous and serrated colon polyps Z86.0102 Personal history of hyperplastic colon polyps Z86.0109 Personal history of other colon polyps Z86.19
Personal History of Other Infectious and Parasitic Diseases
Z87.11
Personal History of Peptic Ulcer Disease
Z87.19
Personal History of Other Diseases of The Digestive System
Description Upper GI series and upper endoscopy/esophagogastroduodenoscopy (EGD) both examine the upper GI tract; however the procedures are very different.

Upper GI series An upper gastrointestinal (GI) series, sometimes called a barium swallow, is an X-ray procedure that uses a contrast agent (barium) to visualize the upper part of the digestive system, including the esophagus, stomach, and the first part of the small intestine (duodenum).

Upper GI endoscopy or EGD Uses a flexible fiber-optic scope with a light and camera to examine the upper part of the GI system. The scope is inserted through the mouth into the upper GI tract to view the esophagus, stomach, and duodenum through the camera.

EGD is usually performed to evaluate symptoms of persistent upper abdominal pain, nausea, vomiting, and difficulty swallowing or bleeding from the upper GI tract. This procedure is more accurate than x-ray imaging for detecting inflammation, ulcers, or tumors of the esophagus, stomach and duodenum and can detect early cancer, as well as distinguish between benign and malignant conditions when biopsies of suspicious areas are obtained.

EGD is indicated in the screening and diagnostic evaluation of signs and symptoms of a wide variety of GI disorders as well as for therapeutic interventions. EGD is indicated for the diagnosis of conditions such as, but not limited to, gastritis, celiac disease, esophagitis, esophageal varices, GERD, and ulcers. EGD may also be indicated for the investigation upper gastrointestinal symptoms. Abnormal imaging or caustic ingestion may also indicate the need for EGD.

19

Summary
The quality of medical evidence concerning the safety and efficacy of EGD is lacking for the majority of the most common uses of the technology. In an effort to guide clinical practice and to provide safe recommendations in the use of EGD, the American Society for Gastrointestinal Endoscopy (ASGE), the American Gastroenterological Association (AGA), and the American College of Gastroenterology (ACG) have established practice guidelines based largely on consensus within these respective specialty medical societies.

In 2012, the ASGE published a broad guideline on appropriate use of GI Endoscopy. The guideline contains several position statements based on a critical review of the available data as well as expert consensus. The ASGE also published the following indication-specific guidelines including
Endoscopy in Gastroduodenal Obstruction and Gastroparesis (2011); Endoscopy in Barrett’s Esophagus and other Premalignant Conditions of the Esophagus (2012); Endoscopy in Dyspepsia (2015); Endoscopy in the Management of Benign and Malignant Gastroduodenal Obstruction (2021).
The indication-specific guidelines also contain recommendations based on consensus and a review of the literature. The ACG has also published indication-specific clinical practice guidelines on the use of endoscopy in commonly encountered clinical scenarios, such as Diagnosis and Management of Barrett's Esophagus (Shaheen 2022), Gastroparesis (Camilleri, 2022), and Diagnosis and Management of Achalasia (Vaezi, 2020).

Medically necessary indications are largely based on ASGE, ACG and AGA recommendations that are graded as moderate to high quality.

Policy History Date Action 11/2025 Clarified coding information.
8/2025 New policy describing medically necessary and investigational indications. Effective 8/1/2025. Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines References

1. American Gastroenterological Association; Spechler SJ, Sharma P, Souza RF, et al. American Gastroenterological Association medical position statement on the management of Barrett's esophagus. Gastroenterology. 2011; 140(3):1084-1091.
2. ASGE Standards of Practice Committee, Banerjee S, Cash BD, Dominitz JA, et al. The role of endoscopy in the management of patients with peptic ulcer disease. Gastrointest Endosc. 2010; 71(4):663-668.
3. ASGE Standards of Practice Committee, Early, DS., Ben-Menachem, T., et al. Appropriate use of GI endoscopy. Gastrointest Endosc. 2012; 75:1127.
4. ASGE Standards of Practice Committee, Evans JA, Chandrasekhara V, Chathadi KV, et al. The role of endoscopy in the management of premalignant and malignant conditions of the stomach. Gastrointest Endosc. 2015; 82(1):1-8.
5. ASGE Standards of Practice Committee, Jue TL, Storm AC, Naveed M, et al. ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction. Gastrointest Endosc. 2021; 93(2):309-322.e4.

20

6. ASGE Standards of Practice Committee, Shen, B., Khan, K., et al. The role of endoscopy in the management of patients with diarrhea. Gastrointest Endosc. 2010; 71(6):887-892.
7. ASGE Standards of Practice Committee; Early DS, Ben-Menachem T, Decker GA, et al. Appropriate use of GI endoscopy. Gastrointest Endosc. 2012; 75(6):1127-1131.
8. ASGE Standards of Practice Committee; Evans JA, Early DS, Fukami N, et al. The role of endoscopy in Barrett's esophagus and other premalignant conditions of the esophagus. Gastrointest Endosc. 2012; 76(6):1087-1094.
9. ASGE Standards of Practice Committee; Evans JA, Muthusamy VR, Acosta RD, et al. The role of endoscopy in the bariatric surgery patient. Surg Obes Relat Dis. 2015; 11(3):507-517.
10. ASGE Standards of Practice Committee; Fujii-Lau LL, Thosani NC, Al-Haddad M, et al. The role of endoscopy in the diagnosis of malignancy in biliary strictures of undetermined etiology: summary and recommendations. Gastrointest Endosc. 2023; 98:685-693.
11. ASGE Standards of Practice Committee; Fukami N, Anderson MA, Khan K, et al. The role of endoscopy in gastroduodenal obstruction and gastroparesis. Gastrointest Endosc. 2011; 74(1):13-21.
12. ASGE Standards of Practice Committee; Khashab MA, Vela MF, Thosani N, et al. ASGE guideline on the management of achalasia. Gastrointest Endosc. 2020; 91(2):213-227.
13. ASGE Standards of Practice Committee; Muthusamy VR, Lightdale JR, Acosta RD, et al. Role of endoscopy in the management of GERD. Gastrointest Endosc. 2015; 81(6):1305-1310.
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32. Spechler SJ, Sharma P, Souza RF, et al. American Gastroenterological Association medical position statement on the management of Barrett’s esophagus. Gastroenterology 2011; 140(3):1084-1091.
33. Vaezi MF, Pandolfino JE, Yadlapati RH, et al. ACG clinical guidelines: diagnosis and management of achalasia. Am J Gastroenterol. 2020; 115(9):1393-1411.
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38. Giardiello, Francis M et al. Guidelines on Genetic Evaluation and Management of Lynch Syndrome:
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40. Stuart J Spechler, MD, Rhonda F Souza, MD. UpToDate: Barrett’s esophagus: surveillance and management.

    Endnotes

    1 Based on expert opinion