# Dx coding for Gastroparesis and Anorexia



## fredcpc (Dec 27, 2010)

I have a Doctor's Impression statement  that reads, "Anorexia and Gastropareis." And Gastroparesis can be a cause of Anorexia. So is the "and" enough to Code First the Anorexia then the Gastropareis? Or, do we code them completely separate?


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## btadlock1 (Dec 27, 2010)

I'd code them separately - Gastroparesis can also be caused by diabetes, so the etiology of Anorexia should be primary. I wouldn't read too much into the "and" - I think the doctor's just saying that the patient has both. I would think the order of the conditions says something, though. The doctor listing Anorexia first tells me that he considers it the main issue. I might be wrong about that, though - a good way to check is to see if the note indicates anorexia, or anorexia nervosa. If it is anorexia nervosa, then it's a safe bet that it's the etiology, not the manifestation. If not, then you'll have to rely on the body of the note to give you context clues as to whether the chicken or the egg came first.


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## preserene (Dec 27, 2010)

Anorexia nervosa is one of the underlying causes of gastroparesis (delayed emptying of the stomach due to a sort of  vagus paralysis or paresis for which one reason being anorexia nervosa. The codes i would assign are 307.1, 536.3.
There is yet another anorexia (plain) which is just loss of appetite(783.0). Since your doctor documented "anorexia" alone you could very well clarify with him or her.
But the syndrome associated with gastroparisis is Anorexia nervosa.


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## fredcpc (Dec 27, 2010)

*dx coding for gastroparesis*

THanks, I think that I came up with the same thing....

Do you remember the EKG encounter we discussed for a while? I think that I have the answer. 
I am going with a 99214 (no modifier) plus 93000 (difficult choice), and both are linked to 786.50 and V45.82, which post RCA and and stent(actually a PTCA or V45.82). It is perfect. 

My questions are can I used the V45.82 in my part A of the MDM? And any other feedback?


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## btadlock1 (Dec 27, 2010)

I don't think the V-Code fits in with the MDM. The doctor makes it pretty clear that he doesn't think they're related, with the word "noncardiac" describing the chest pain. So I wouldn't take it into consideration for the current diagnosis or treatment options, and the note's not really clear that the doctor ordered or reviewed old record records relevant to the V-code's description (such as the surgical note from the stent); only the past chest x-ray, if I remember correctly (which is really non-specific). The past cardiac conditions are ruled out of the risk portion, also, because the current exam shows no indication of current cardiac complications, so I'd think factoring either in the MDM is really a stretch. At this point, they're more informative than problem-pertinent.


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## fredcpc (Dec 27, 2010)

*V45.82*

You are right about the non-cardiac pain statement. But the statement was "suspect this is non-cardiac pain, probably chest wall." The dr. recommended Darvocet, which is a risky pain reliever. However, he also Rx'd Nitroglycerin. He also did an EKG.

Also, the patient also had a brother that died of an MI. You may be right here, but why the Nitro?


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## fredcpc (Dec 27, 2010)

*dx coding for gastroparesis*

Preserene -- I am a remote coder, so I can not ask anyone. Wish I could. The Anorexia Nervosa dx code, first, would make more sense, but the doctor only mentioned Anorexia. So my only choice is to code Anorexia then Gastroparesis.


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## fredcpc (Dec 27, 2010)

*V45.82*

Also, the doctor's office originally coded a 414.01, which is RCA. The V45.82 just means that she had PTCA in the past. So, I don't know, but I am going to sleep on it.


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## preserene (Dec 27, 2010)

Hi Fred, I am sorry. 
Well in that case you are right, when doctor did not document we cannot assume the diagnosis.
But for indepth insight and for relevance of the scenario, I just jot down some points here:
anorexia= Loss of appetite, especially as a result of disease. This could be temporary or a chronic illness an dto my knowledge this does not land up with neuronal entity , like gastroparesis
Anorexia nervosa= is usually a teenager's self inflicted disorder- an eating disorder characterized by refusal to maintain a healthy body weight and an obsessive fear of gaining weight, admixed with cognitive biases] Persons with anorexia nervosa continue to feel hunger, but deny themselves all but very small quantities of food. The average caloric intake of a person with anorexia nervosa is 600-800 calories per day, but in extreme cases self-starvation is more extreme.It is a serious mental illness with a high incidence of comorbidity .It is this type of anorexa nervosa which causes gastroparesis.
Anorexia nervosa is the one which is attributed to gastroparesis always and it merits for primary diagnosis.
But anorexia as such (illdefined) ,would it merit for prim diagnosis (when there is yet  another diagnosis available)?
If there are more info about age, symptoms, past history ,signs available, you can be sure of. 
It is so hard, sometimes the doctors make us rack our head!!!


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## preserene (Dec 27, 2010)

fredcpc said:


> You are right about the non-cardiac pain statement. But the statement was "suspect this is non-cardiac pain, probably chest wall." The dr. recommended Darvocet, which is a risky pain reliever. However, he also Rx'd Nitroglycerin. He also did an EKG.
> 
> Also, the patient also had a brother that died of an MI. You may be right here, but why the Nitro?



The probability, suspecious sort of diagnosis still do not rule out the opposite conditions-here it still do not rule out the  cardiac pain too; And all the more when there is a strong sibling history of MI and the medical necessity to prescribe Nitro by the doctor- means he wants to rule out unstable angina, angina pectoris still ; if the pain still not relieved with nitro, doctor cannot rule out cardiac like MI


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## fredcpc (Dec 28, 2010)

*dx coding for gastroparesis*

Preserene -- Thank you for clinical coding information. I think this could be your specialty. So here is a question for you: How would code the following and in what order?

1) Anorexia and Gastroparesis. Will continue meoclopramide and resume two week course of Megace.
2) Shoulder Bursitis. Patient consented for corticosteroid injection for management. Skin was prepped with alcohol x2, anesthetized with topical ethyl cloride....A 22-guage needle was introduced in the subacromial space easily. The space was injected with 4ml of 40 mg of Triamcionlone and lidicaine. 

Your thoughts??


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## btadlock1 (Dec 28, 2010)

You don't get any clear cut ones, do you? 
The doctor is sending some pretty mixed messages about the chest pain - I can't tell you how the nitro fits in...Really, the "non-cardiac" is probably irrelevant, since the doctor used the word "suspect" (assuming this is outpatient)...Can't code for suspected conditions - only definitive Dx, or signs/symptoms. So back to the drawing board...The RCA may be a relevant comorbidity, although I still don't see a way to fit the stent into the MDM. Anyways, I think you're safe with a 99214 and Dx codes you mentioned. 

Reading the note on the Anorexia patient - I can see why you're unsure. So there's no mention of any psych treatment recommendations? It's odd to me that the doctor would prescribe medication to treat a loss of appetite without dealing with the psychiatric aspect of anorexia, if he was referring to anorexia nervosa.


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## fredcpc (Dec 28, 2010)

*V45.82*

I am going to change the Doctor's listed heart code 414.01 to a V45.82. It is a slight risk, but even then it will not hurt me that much. Here is why:

1) The doctor listed history of "RCA stent in 2004." Meaning a PTCA with stent Px.
2) He gave a trail Rx of Nitroglycerin, which is only for patient that have chest pain due to CAD or angina. It is never given out to patients with just normal, run-of-the-mill chest pain. Nitro is pretty extreme drug, heck, the military uses it in weapons.
3) The doctor said he will perform a Myoview Stress Test if problems continue.
4) The doctor put the dx 414.01 on the claim form. This is definitely an incorrect code, but shows a line of thought. So I am going to replace it with V45.82.

So, yeah, it is a slight risk. But I ask my this question, does it affect the tx? I would say "yes", because of the Nitro.


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## btadlock1 (Dec 28, 2010)

I was kind of wondering the same thing - I wasn't sure if that would qualify as "drug therapy requiring intensive monitoring for toxicity" or not. But then I decided that that category is probably reserved for chemotherapy, and similar drug therapies - I'd like to know if that's correct. 

I don't think it will have an effect on the overall code, even if you can use it to apply a higher risk level in the MDM. I wouldn't count the "possible Myoview in the future" towards anything, because it wasn't actually ordered or reviewed - it may never even happen - it's just an afterthought. You still only have a detailed history and exam documented, so a high MDM won't get a 99215, just a more solid 99214. 

It's totally irrelevant, but the fact that she was having cardiac problems and taking Darvocet _really_ makes me wonder if the Darvocet was related to the problems somehow (with the FDA recall, and whatnot). Just something to ponder!


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## fredcpc (Dec 28, 2010)

*Darvocet...new encounter to look at...*

I am staying with 99214, my thoughts were just on the secondary dx code. Ok, new encounter below....

Would you mind looking at another one for me, it is kinda different as are many of these I am posting. I just looking for just a HPI level here:

HPI: He complains of left hip pain with activity such as walking or shoveling. He thinks ED started at the same time of his hip surgery. He has a normal libido. He is interested in meds for ED. He thinks that fasting blood glucoses are ranging about 170 to 150. Denies polyuria or polydipsia.

Now the MDM: 1) DM. Suspect control will be poor. Need f/u glycohemoglobin and urine micro alubumin. He may need to add sulfourea to regimen to achieve glycemic control.  2) HTN. Control is good. Will continue same antihypertensive regimen. Need clarification on atenolol usage. 
3) Actinic Keratosis. With pts consent, 6 keratoses were destroyed using liquid nitrogen dual freeze technique.
4) Dyslipidemia. Needs F/u lipid panel to monitor gemfibrozil use.

I alread know the CPT code for the Karatosis. I am just looking for the MDM level. Thoughts? Feedback??


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## btadlock1 (Dec 28, 2010)

HPI: 
He complains of left hip pain *(HPI Location or ROS M/S)*
with activity such as walking or shoveling. *(HPI Context)*
He thinks ED started at the same time of his hip surgery. *(HPI - Associated signs/symptoms or timing)*
He has a normal libido. *(ROS - GU)*
He is interested in meds for ED. *(HPI - Modifying Factor? It's a stretch, if so)*He thinks that fasting blood glucoses are ranging about 170 to 150.  *(ROS - Endocrine or maybe HPI severity)*
Denies polyuria or polydipsia. *(ROS - GU and Endocrine)
Enough for a detailed, but not enough for comprehensive history. There are easily 4 HPI and 2+ ROS. Your PFSH will determine the overall history.*

Now the MDM: 
1) DM. Suspect control will be poor. *(Type II Diabetes, Uncontrolled - Connotation suggests this is a new diagnosis [to this provider], perhaps referred to a specialist for diabetic management? If so, this may be a new patient altogether.) *
Need f/u glycohemoglobin and urine micro alubumin. *(Data - Labs Ordered)*
He may need to add sulfourea to regimen to achieve glycemic control. *(Rx Management?)*
2) HTN. Control is good. Will continue same antihypertensive regimen. Need clarification on atenolol usage. *(New problem, stable, with drug therapy; Data - decision to discuss case with another physician; Rx management)*
3) Actinic Keratosis. With pts consent, 6 keratoses were destroyed using liquid nitrogen dual freeze technique. *(Co-morbidity)*
4) Dyslipidemia. Needs F/u lipid panel to monitor gemfibrozil use. *(Co-morbidity, lab ordered, Rx management)

I get Extensive Dx/Tx, Limited Data, Moderate Risk = Moderate MDM*


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## preserene (Dec 28, 2010)

Fred,

Treatment  favors the anorexia and gastroparesis more. So his document is very much synchronysing with them.
In that case, I would like to give gastroparesis the primary diagnosis than the illdefined condition.

Megace is used in treating loss of appetite (as an appetite stimulant). Loss of appetite can be caused by both medical and emotional sickness. Anorexia is a generalized term given to a condition with some underlying disease process where as nervosa is an entity by itself and has a definite neuronal factor (psychiatric component) contributing to it and patients are severely anorexic and look very cachatetic.
Metachlopramide is an antiemetic and gastroprokinetic agent.
So the physician has aimed at treating symptomatically for anorexia (loss of appetite) and gastroparesis. May be patient had nausea also( not necessarily though)
At this stage  the physician has been very meticulous in documenting the diagnosis as the anorexia and gastroparesis, with the prevailing symptoms and signs he finds in the patients. 

[Before 1980, Nervosa was not officially classified as psychiatric but now it is different] 
              ...................................................................
As regards Darvoset, 

it is used to treat mild-to-moderate pain. It contains two different medications, acetaminophen (Tylenol®) and propoxyphene napsylate (Darvon-N®). Darvocet is used both for short-term pain (such as after a surgery or dental procedure) and for long-term pain control. Because it contains a narcotic, many healthcare providers like to limit Darvocet use to the shortest period of time possible.
Moreover narcotic is a medication of choice for the relief of cardiac pain though it is said to have some changes in cardiac rhythm and it is only a prescription drug  by by Physicians, who use them with great caution and with great limitations. 
Thank you for this opportunity and your time.


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## fredcpc (Dec 28, 2010)

*dx coding for gastroparesis*

Thank you for the workup. Nice.  The ROS is Comp; and the PFSH is also Comp. So we have a detailed History. 

The DM and HTN are actually on follow up, but it may not make a difference in the MDM. But this leads to my real question. 

1) Which of the guidelines did you use to grade the HPI?

2) What is your take on HPI as it relates to chronic problems and the 1995 guidelines? I feel good about some of my codes, but this is a shady area.


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## fredcpc (Dec 28, 2010)

*dx coding for gastroparesis*

It sounds like you have a lot of knowledge on the subject. But the ICD-9 book states under the Gastroparesis, to "Code First any Underlying disease or illness." Isn't Anorexia the underlying illness? Or are you saying they are unrelated?


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## preserene (Dec 28, 2010)

I had been giving a long thought over it. I was wondering how to assign when the icd says so. But the realty in medicine is what I said. If the doctor documented it as A.nervosa, the matter is so simple. Nervosa doubtlessly takes the priority but the same ICD guidelines about the ill defined condition , does not allow us to do so. 
One thing for sure this anorexia in its true sense do not lead to gastroparesis as A.nervosa does. Now you are the Boss sequence as you find it right. 
SO, they have to be coded as "AND" to its true sense or as it has yet another say "OR"!!
 Can we be off the hook?? in so doing!!


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## btadlock1 (Dec 28, 2010)

fredcpc said:


> Thank you for the workup. Nice.  The ROS is Comp; and the PFSH is also Comp. So we have a detailed History.
> 
> The DM and HTN are actually on follow up, but it may not make a difference in the MDM. But this leads to my real question.
> 
> ...



I think that the doctor should have listed hip pain in his Impression statement, since it was part of the chief complaint; the same can be said about erectile dysfunction. That would have made their significance to this visit more obvious. 
I'm using whichever one has the # of elements (Location, Quality, Severity, etc.) - I count 4 that I'm confident about, which adds up to extended HPI. (I have an audit tool that doesn't specify 95 or 97 - either are acceptable) But I also think you've got 3+ chronic conditions - diabetes, ED, and HTN. Depending on how long ago surgery was, it may be chronic hip pain as well.


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## fredcpc (Dec 28, 2010)

*dx coding for gastroparesis*

Yeah, I like those audit tools. Wish I had one. But do the 1995 allow you to count chronic conditions or status on HPI? this is a really key area and will make difference in my EM levels. What is your take on this?


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## btadlock1 (Dec 28, 2010)

Why does it have to be one or the other? Either rule is acceptable. But, apparently, I used 1995 guidelines:
_The HPI is a chronological description of the development of the patient's present illness from
the first sign and/or symptom or from the previous encounter to the present. It includes the
following elements:
• location,
• quality,
• severity,
• duration,
• timing,
• context,
• modifying factors, and
• associated signs and symptoms.
Brief and extended HPIs are distinguished by the amount of detail needed to accurately
characterize the clinical problem(s).
A brief HPI consists of one to three elements of the HPI.
!DG: The medical record should describe one to three elements of the present
illness (HPI).
An extended HPI consists of four or more elements of the HPI.
!DG: The medical record should describe four or more elements of the present
illness (HPI) or associated comorbidities._ - 1995 Guidelines

Mine is from Trailblazer, but I'm sure your local carriers have their own available online. 
(This is what mine looks like, in case you were curious.) http://www.e-medtools.com/Aqua_Medicare_Coding_Worksheet.html


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## fredcpc (Dec 28, 2010)

*dx coding for gastroparesis*

Which guidelines you use does make a difference on your EM level. Here is something I just found on E/M university....

Both the 1995 and 1997 E/M guidelines allow the HPI to be completed by using the so-called HPI elements which are used to further describe a specific somatic complaint (e.g. chest pain).  In clinical settings where there is no such complaint from the patient, the 1997 E/M guidelines (but not the 1995 rules!) offer the option of completing the HPI by commenting on the status of chronic or inactive problems. 

Unless I am being overly analytical, we don't count the chronic histories with the 1995 Guidelines. Thoughts?


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## btadlock1 (Dec 29, 2010)

No, I don't believe so, but the point is, you don't have to use only 1995 or 1997 guidelines specifically - either one is acceptable. I tend to use the 1995 guidelines, because they're just easier for me - it's a matter of personal preference, and the policies you have to follow. The 1997 guidelines added the status of 3 chronic conditions for situations like the one you mentioned. As long as you know how you got your code selection, you should be fine.


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## fredcpc (Dec 29, 2010)

*1995 Guidelines*

The medical record should describe elements of the present illness (HPI) or associated morbilities (1995 guidlines)

The medical record should describe elements of the present illness (HPI) or the status of atleast 3 chronic or inactive consitions (1997 guidlines).

Like you, I started with a 1995 preference, the exams seem more realistic. But I am working my way back to 1997.

Mahalo,
Fred


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