Anesthesia Coding Alert

The causes of chronic abdominal pain range from the identifiable, such as Crohn's disease, hernias, lesions, hematomas, desmoid tumors and myofascial tears, to the idiopathic, when pain is not related to a specific physiological source. Increasingly, patients with chronic abdominal pain are turning to pain management physicians. Consequently, pain management coders should become familiar with the treatment options associated with chronic abdominal pain and the diagnoses that support their medical necessity. Diagnosis and treatment of the sources of chronic abdominal pain vary, depending on the severity of symptoms and the patient's response to treatment. Common treatments include nutrition counseling, physical therapy, trigger point injections, nerve blocks and, in more severe cases, intrathecal pain therapy, nerve destruction and surgery. Patients with certain conditions, such as Crohn's disease (555.9), also may experience symptoms of rheumatoid arthritis (714.xx) and require treatments associated with this secondary diagnosis. Intra-abdominal Pain Recent studies have suggested that patients suffering from chronic intra-abdominal pain caused by conditions such as Crohn's disease and abdominal adhesions related to previous surgeries benefit not only from treatments to control inflammation but also from nerve blocks.

For Crohn's patients, anti-inflammatory medications include steroids and Azulfidine, which is also called sulfasalazine and salazopyrene. Mary Klein, CPC, coding specialist with Panhandle Medical Services Inc. in Pensacola, Fla., notes that Azulfidine is an oral medication. Since it is not an injectable drug, it does not have a corresponding J code." According to the local medical review policy (LMRP) for Blue Cross Blue Shield of Kansas, infliximab (J1745) infusion also has demonstrated clinical efficacy in patients with moderate to severe Crohn's disease who have not responded to other treatments. In addition, infliximab can reduce the symptoms of rheumatoid arthritis in patients who have not responded to methotrexate. The LMRP includes the following covered diagnosis codes: 555.0-555.9 (Regional enteritis) and 714.0 (Rheumatoid arthritis). ICD-9 Codes 565.1 (Anal fistula) and 569.81 (Fistula of intestine, excluding rectum and anus) are listed as secondary diagnoses to be used with the codes for Crohn's disease. Klein notes that infliximab is administered by IV during a two-hour period, with the patient monitored during and after administration for any adverse reaction. "Most of the immediate reactions would be of the allergic type. However, the drug has some possible late reactions that the physician may need to monitor over a period of days or weeks."

Klein says the physician should be the one who monitors the patient during and after infusion. Therefore, 90784 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; intravenous) can be used to report the IV administration. Coders, however, should check with the physician and the LMRPs of their insurance carriers regarding a physician's role [...]