ICD-10 and CPT Coding for Post-Bariatric Surgery Patient with Multiple Complaints
ICD-10 Diagnosis Codes
Primary Diagnoses:
- Z98.84 - Bariatric surgery status (history of gastric sleeve surgery) 1
- K91.2 - Postsurgical malabsorption, not elsewhere classified (persistent vomiting post-gastric sleeve) 1
- H60.93 - Unspecified otitis externa, bilateral (bilateral ear canal erythema) 1
- R10.11 - Right upper quadrant pain (constant RUQ pain) 1
- R10.9 - Unspecified abdominal pain (diffuse abdominal pain) 1
- R11.10 - Vomiting, unspecified (post-meal vomiting) 1
- R50.9 - Fever, unspecified (nightly low-grade temperatures) 1
Secondary/History Diagnoses:
- D51.0 - Vitamin B12 deficiency anemia (documented PMH) 1
- E56.9 - Vitamin deficiency, unspecified (at-risk post-bariatric surgery patient requiring monitoring) 1
CPT Procedure Codes
Laboratory Tests:
- 85025 - Complete blood count (CBC) with automated differential WBC 1
- 80053 - Comprehensive metabolic panel (CMP) 1
- 80061 - Lipid panel 1
- 84443 - Thyroid stimulating hormone (TSH) 1
- 84480 - Triiodothyronine T3, total 1
- 84436 - Thyroxine (T4), total 1
- 86038 - Antinuclear antibodies (ANA), titer 1
Imaging:
- 74018 - Radiologic examination, abdomen; 1 view (AP supine abdominal X-ray) 1
Medications/Procedures:
- J3420 - Injection, vitamin B12 cyanocobalamin, up to 1000 mcg (if B12 injection given; not documented but relevant given PMH) 1
- 99213 or 99214 - Office or other outpatient visit for evaluation and management of established patient (based on complexity and time; this case involves multiple chronic conditions and extensive workup suggesting 99214) 1
Critical Coding Considerations for Post-Bariatric Surgery Patients
Bariatric Surgery-Specific Monitoring Requirements:
- Post-bariatric surgery patients require lifelong monitoring for nutritional deficiencies including vitamin B12, which should be checked every 6 months initially, then annually 1
- The persistent vomiting (K91.2) is a recognized complication requiring evaluation for surgical complications such as stricture, band slippage, or gastric stenosis 1
- Vitamin B12 deficiency is expected post-gastric sleeve due to reduced hydrochloric acid production and intrinsic factor availability 1
Documentation Support for Medical Necessity:
- The extensive laboratory workup (CBC, CMP, lipid profile, thyroid panel, ANA) is justified by the patient's post-bariatric surgery status, documented B12 deficiency anemia, persistent vomiting, and systemic symptoms (fever, fatigue) 1
- Abdominal imaging is appropriate given RUQ pain and post-surgical status to rule out complications 1
- Ofloxacin ear drops are appropriate for bilateral otitis externa with erythema 1
Common Pitfalls to Avoid:
- Do not code obesity (E66.x) if the patient has already undergone bariatric surgery and maintained weight loss; use Z98.84 instead 1
- Always link the B12 deficiency anemia (D51.0) to the bariatric surgery status (Z98.84) as this establishes medical necessity for ongoing monitoring 1
- The persistent vomiting post-gastric sleeve warrants K91.2 rather than simple R11.10, as it represents a recognized post-surgical complication requiring specific management 1