Gastroenterology Coding Alert

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Does your physician diagnose and treat many patients who have celiac disease? Then you need to really be on top of your E/M coding game to maximize reimbursement.

Celiac disease (579.0) is a genetically based intolerance to gluten, a protein found in wheat, barley, rye, and oats. The treatment is for the patient to avoid foods that contain gluten. That sounds simple enough, but the condition can be fiendishly difficult to diagnose.

Symptoms vary and are not always gastrointestinal. You need to be familiar with counting history of present illness; personal, family, and social history; and review of systems elements, and you need to know that widely disparate symptoms and history items may pertain to this complex and often puzzling disease.

Celiac disease may affect 3 million Americans -- or 0.5 percent to 1 percent of the U.S. population. Occasionally, symptoms appear during childhood, and sometimes they don't appear until adulthood. The manifestations of celiac disease range from no symptoms to overt malabsorption with involvement of multiple organ systems and an increased risk of some malignancies, according to an American Family Physician article.

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," says Stefano Guandalini, MD, professor of pediatrics and gastroenterology section chief at the University of Chicago's Comer Children's Hospital.

"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," Guandalini says. "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 meet only a low level of coding."

To confirm gluten intolerance, your physician can order a blood test 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, Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple, if your physician performs a complete EGD).

Remember: Only report 44361 or 43239 once, even if your physician takes more than one tissue sample, said Jan Rasmussen, CPC, ACS-GI, in her Coding Institute audio presentation, "Stellar Strategies for Coding Upper GI Endoscopic Procedures" (www.audioeducator.com).

"No matter how many biopsies are taken, the code is reported only once," she said.

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 a level-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 establishedpatient 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.

Review the 14 Body Systems

When you determine the level of E/M your physician provides, you need to know how many of the patient's body systems he's reviewed. Here are the 14 systems to choose from:

• Constitutional: Fevers, chills, weight loss, etc.?

• Gastrointestinal: Nausea, vomiting, abdominal pain, bowel movement routine, etc.?

• Genitourinary: Nocturia, frequency, pain, etc.?

• Cardiovascular: Chest pain, palpitations, syncope, edema, etc.?

• Respiratory: Shortness of breath, sleep apnea, etc.?

• Eye: Glasses, double or blurred vision, cataracts, etc.?

• ENT: Ringing in ears, infections, nasal congestion, etc.?

• Psychiatric: Mood changes, depression, affect, insomnia, etc.?

• Skin: Rashes, hives, discolorations, etc.?

• Musculoskeletal: Joint pain, muscle pain or cramping, stiffness, etc.?

• Integumentary: Growth or loss of hair, itching, rashes, etc.?

• Endocrine: Excessive sweating, excessive hunger or thirst, etc.?

• Hematologic/Lymphatic: Bleeding problems, bruising, anemia, etc.?

• Allergic/Immunologic: Immune problems, allergy reactions, etc.