Gastric intestinal metaplasia without dysplasia, unsp site

This code signifies the presence of gastric intestinal metaplasia (GIM) where the normal stomach lining has transformed to resemble intestinal tissue, but without any evidence of abnormal cell growth (dysplasia). It indicates a pre-malignant condition that requires surveillance but is not yet cancerous. The "unspecified site" denotes that the exact location within the stomach is not documented.

Use this code when documentation confirms gastric intestinal metaplasia without dysplasia, and the specific anatomical site (e.g., antrum, body, cardia) is not specified in the pathology report or clinical notes. This code is appropriate for patients undergoing endoscopic surveillance or follow-up for GIM. Documentation must explicitly state "without dysplasia."

• Do not use this code if dysplasia is present; instead, refer to codes for gastric dysplasia.
• Prioritize more specific codes if the site of the gastric intestinal metaplasia is documented (e.g., K31.A11 for antrum, K31.A12 for body).
• Ensure the pathology report or physician's notes clearly state "without dysplasia" to support the use of this code.