Perforation of esophagus

This code signifies a hole or tear in the wall of the esophagus, the muscular tube connecting the throat to the stomach. This perforation can result in leakage of esophageal contents into surrounding tissues, leading to serious complications such as mediastinitis or sepsis.

Apply this code when documentation clearly indicates a disruption of the esophageal wall, whether spontaneous, iatrogenic (e.g., post-endoscopy), or due to trauma or disease. Supporting documentation includes operative reports, endoscopy reports, imaging studies (e.g., esophagram), and physician notes detailing the perforation.

• Differentiate between perforation and a simple esophageal tear or laceration without full-thickness involvement.
• Always look for an underlying cause or associated condition to code first, if applicable (e.g., foreign body, caustic ingestion, surgical complication).
• Specify the site of perforation if documented (e.g., cervical, thoracic, abdominal esophagus) using more specific ICD-9-CM codes if available.