Gastroenterology Coding Alert

Overcome this coding challenge

Reporting for Crohn's patients can make your head spin, but it doesn't have to be that difficult. We-ve consulted with the experts to help you increase your reimbursement for Crohn's diagnosis, management and treatment.
 
Crohn's disease, also called ileitis or regional enteritis, is an inflammatory bowel disease (IBD) that typically irritates the small intestine but can also be found in any part of the digestive tract. Those with Crohn's disease have frequent pain from intestinal inflammation and often have diarrhea. There is no cure for Crohn's disease, but several treatments are available.
 
In many gastroenterology offices, not much time passes between visits from patients with Crohn's disease, says Lois Curtis, CPC, of Gastroenterology Associates in Evansville, Ind.
 
-You go in spurts sometimes: You get a lot (of Crohn's patients), and then it tapers off a while,- she says. -But we-re always getting patients with Crohn's or diagnosing patients with it.-

1. Identify the Consultation Visits

Often a gastroenterologist's first encounter with a Crohn's patient is a -referral.- The patient has some sort of gastroenterological problem, and her primary-care physician decides that a gastroenterologist's opinion is needed.
 
Even if another physician diagnoses a patient with Crohn's and she eventually comes under your office's care, the initial meeting with her is still a consultation.
 
If the patient reports initially because she (or her doctor) decided that a gastroenterologist's opinion was in order, choose the appropriate code from the outpatient consultation codes 99241-99245 (Office consultation for a new or established patient ...).
 
-This is how most patients with Crohn's symptoms end up on our office's appointment books,- says Delia Bartolotto-Stewart, CPC, of Digestive Health Physicians in Fort Myers, Fla. -A patient has a pain or diarrhea problem, the (primary-care) doctor isn't sure if it's Crohn-s, so our office determines that.-
 
If the gastroenterologist provides a second or third opinion about a patient with Crohn's symptoms, you should assign one of the outpatient office visit codes (99201-99205 for new patients, or 99211-99215 for established patients) or consult codes (99241-99245), whichever is appropriate for your setting and type of service.

2. Code the Diagnostic Method

Gastroenterologists have several options when testing for Crohn's disease. They can order simple blood tests to measure for an abnormally high number of white blood cells or a high sedimentation rate, a sign of inflammation somewhere in the body. They can also order fecal-occult blood tests to detect intestinal bleeding, a problem common to Crohn-s.
 
Physicians most often use the guaiac-based fecal-occult test because of its sensitivity to lower-bowel bleeding. The proper CPT code for this test is 82270 (Blood, occult, by peroxidase activity [e.g., guaiac],  qualitative; feces, consecutive collected specimens with single determination, for colorectal neoplasm screening).

Perhaps the most common way to test for Crohn's is with colonoscopy, during which the physician can check for inflammation or bleeding and take tissue for biopsy. The gastroenterologist will often examine the terminal ileum, and the standard colonoscopy codes include this procedure. You should not report an additional small-bowel enteroscopy with the colonoscopy code. Choose the appropriate code from the colonoscopy group (45378-45387) when your physician uses this diagnosis method.
 
Curtis says that her doctors opt for colonoscopies most of the time due to the thoroughness of the procedure.
 
-It really depends on what kinds of symptoms the patient presents with, but ideally, if they [doctors] suspect that a patient has Crohn-s, the test of choice would be colonoscopy,- Curtis says. -They can actually see what's taking place in the colon and find any irregularities causing the symptoms.-
 
Colonoscopies are a common diagnostic tool because biopsy is possible and the mucosa of the intestines (visible during a colonoscopy) can be a sign of Crohn's in a patient.
 
-If the test has the look of the mucosa of a Crohn's patient, then a doctor can pretty much spot it [Crohn-s] at that point in time,- Curtis says.

3. Code the Treatment Option

Once a gastroenterologist diagnoses Crohn's disease, he chooses among several options for treatment. Changes in diet and lifestyle are always the first steps, along with medication containing the anti-inflammatory agent mesalamine, such as sulfasalazine, Asacol, Dipentum or Pentasa. Another medication option features drugs that suppress the immune system -- such as 6-mercaptopurine and azathioprine -- along with corticosteroids to control inflammation.
 
Partial colectomies and small-bowel resections are occasionally necessary surgeries for Crohn's patients, but often the inflammation returns to the very area from which the intestine was removed. Sometimes the condition is so serious that a total colectomy is needed. If a patient has a partial or total colectomy, report the procedure using the appropriate code from 44140-44160 (Colectomy ...).
 
Patients may also require surgery to address symptoms not responding to medical therapy or to correct blockages, perforations, abscesses or intestinal bleeding.
 
Physicians often treat moderate-to-severe cases of Crohn's disease with an intravenous infusion regimen using the drug infliximab, more commonly known as Remicade. This is a relatively new -- and costly -- option, so offices must often prove that conventional treatment options failed before using Remicade.
 
-It's a good treatment, but due to the fact that it's so costly, our doctors try to work with patients to see what treatment is most effective for them,- Curtis says.
 
Physicians administer Remicade intravenously in a procedure that often takes at least two hours. This leads some gastroenterologists to perform the infusion at a hospital, but it can also be done in an office or outpatient setting.
 
CPT 2006 revised the infusion codes for Remicade and considers treatment with intravenous biologic agents -- like Remicade -- as chemotherapy. For the first hour of Remicade infusion, use 96413 (Chemotherapy administration, intravenous infusion technique; up to one hour, single or initial substance/drug).
 
Longer infusions also require you to use +96415 (- each additional hour, 1 to 8 hours [list separately in addition to code for primary procedure]). If the gastroenterologist administers other medications to treat allergic reactions, you may also need additional codes.