Gastroenterology Coding Alert

Visits go beyond finding the right dx code – get the scoop here.

If your gastroenterologist diagnoses and treats patients with celiac disease, you’ll have to carefully scrutinize the documentation to select the right codes for each visit.

Celiac disease (K90.0) is an intolerance to gluten, which is found in wheat, barley, rye, and some oats. The standard treatment is for the patient to avoid ingesting gluten. That may sound simple enough, but the condition can be challenging to diagnose.

Symptoms vary and are not always gastrointestinal, so collecting thorough history of present illness; personal, family, and social history; and review of systems elements are essential.

Don’t Make Assumptions Based on Dx

The level of E/M varies depending on the complexity of the presentation, and it has nothing to do with the diagnosis itself. Therefore, there is no one E/M code you can expect to report for celiac patients.

For instance, a patient presenting with symptoms and history suggestive of celiac may undergo a long, complex evaluation requiring intensive workup and thus will meet criteria for a high level of coding. On the other hand, a straightforward young child with family history of celiac, diarrhea, and a celiac screening test already positive is a quick and simple assessment and will typically warrant only a low level of coding.

To confirm gluten intolerance, your physician may order a blood test to look for high levels of anti-tissue transglutaminase antibodies, or he may perform a biopsy of the small intestine (44361,  Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple, if your gastroenterologist uses a pediatric colonoscope or dedicated push enteroscope; or 43239, Esophagogastroduodenoscopy, flexible, transoral; with biopsy, single or multiple, if your physician performs a complete EGD).

Note that it would be somewhat rare to use 44361 for the celiac biopsy, “since this requires going more than 50 cm beyond the pylorus and that would seldom be needed for a celiac diagnosis,” said Glenn D. Lit­tenberg, MD, MACP, FASGE, AGAF, a gastroen­terologist and former CPT® Editorial Panel member in Pasadena, California.

Remember: Only report 44361 or 43239 once, even if your physician takes more than one tissue sample.

Refresh Your History Expertise

The history of present illness (HPI); review of systems (ROS); the patient’s past, medical, family, and social history (PFSH); the extent of the physical exam performed; and the complexity of medical decision making all contribute to reporting the correct E/M code for celiac patients. A detailed history can support up to alevel-three new-patient E/M (99203, ... a detailed history; a detailed examination; medical decision making of low complexity ...) or be part of a level-four established-patient E/M (99214, ... a detailed history; a detailed examination; medical decision making of moderate complexity ...).

A comprehensive history supports a level-four or -five new-patient E/M (99204, 99205) or a level-five established patient E/M (99215). That requires an extended HPI (document four of seven HPI elements); a complete ROS; and a complete PFSH (two or three of the areas).

HPI: History of present illness should be a chronological description of the patient’s current illness. Look for location (example: abdomen), quality (example: nausea), severity (example: limited disease process), duration, timing (example: mornings), context (example: after meals), modifying factors (example: better with change in diet), and associated signs and symptoms (example: fatigue). If you document one to three of these categories, consider this a brief HPI. Four or more of these elements equals an extended HPI.

Symptoms May Point to ROS Level

An extended ROS-- where the physician examines two to nine of the patient’s systems-- is one component of a detailed history; a complete ROS-- 10 or more systems-- is necessary for a comprehensive history.

Look at these symptoms a Celiac patient may have and see how many systems you can identify.

• Recurring bloating, gas, or abdominal pain
• Chronic diarrhea or constipation or both
• Unexplained weight loss or weight gain
• Pale, foul-smelling stool
• Unexplained anemia
• Bone or joint pain
• Behavior changes/depression/irritability
• Vitamin K deficiency
• Fatigue, weakness, or lack of energy
• Delayed growth or onset of puberty
• Failure to thrive (in infants)
• Missed menstrual periods
• Infertility (male and female)
• Spontaneous miscarriages
• Canker sores inside the mouth
• Tooth discoloration or loss of enamel.

In addition to symptoms that the physician records during the exam, the patient’s personal, family, and social history helps inform whether he has celiac disease. A complete PFSH requires your physician to document that he reviewed two or three of the history areas. Here are personal and family history items that may be pertinent to a celiac diagnosis:

• Type 1 diabetes
• Dermatitis herpetiformis
• Thyroid disease
• Osteopenia/osteoporosis
• Irritable bowel syndrome
• Chronic fatigue syndrome
• Fibromyalgia
• Peripheral neuropathy
• Sjögren’s syndrome
• Eczema
• Endomysial antibody (EMA-IgA)
• Tissue transglutaminase antibody (tTG-IgA/IgG)
• Anti-gliadin antibody (AGA-IgG, AGA-IgA)
• Total serum IgA.