Gastric intestnl metaplasia without dysplasia, w the cardia

This code signifies the presence of intestinal metaplasia within the cardia of the stomach, specifically indicating that there are no dysplastic changes observed. Intestinal metaplasia is a precancerous condition where the lining of the stomach is replaced by cells resembling those of the intestine. This particular code specifies the anatomical location and the absence of cellular atypia.

Apply this code when pathology reports confirm intestinal metaplasia confined to the gastric cardia, and explicitly state that no dysplasia is present. This is typically identified during endoscopic biopsy for symptoms such as GERD, Barrett's esophagus screening, or other upper GI complaints. Documentation must clearly specify "cardia" and "without dysplasia."

• Ensure the pathology report explicitly states "without dysplasia" to avoid miscoding more severe conditions.
• Distinguish from intestinal metaplasia in other gastric locations (e.g., antrum, body), which are coded differently.
• Do not use if dysplasia is present; instead, refer to codes for gastric dysplasia or carcinoma in situ.