Gastroenterology Coding Alert

Learn to determine whether the chronic condition is stable.

As a gastroenterology coder, you are likely no stranger to coding for celiac disease — however, that doesn’t mean you’re confident about it. You must rely on thorough documentation while also making sure you’re submitting all the correct details and appropriately leveling the encounter to avoid denials.

Whether your celiac coding skills need some work, or you’re just trying to get a handle at better documenting the disease take a look at this expert insight to bolster your claims.

Understand the Difference Between Celiac Disease and Sensitivity

Though you might find it confusing, celiac disease and gluten sensitivity are different conditions and need to be coded differently. You can report an official celiac disease diagnosis using K90.0 (Celiac disease), while sensitivity should be coded with K90.41 (Non-celiac gluten sensitivity). “An allergic food reaction can be severe or life-threatening, whereas food intolerance symptoms are generally less serious,” explains Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

Both gluten sensitivity and celiac disease cause the body to negatively respond to gluten protein, which is found in food made using grains such as wheat, barley, and rye. Because of these similarities, it’s easy to confuse the two conditions and miscode an encounter. Keep in mind that gluten sensitivity causes minor, short-term symptoms such as stomach pain and bloating. However, celiac disease causes long-term health problems such as nutrient malabsorption and bowel damage in addition to stomach aches and bloating. Pay close attention to the documentation and query the provider if you can’t find a definitive diagnosis for either condition.

Note: If the patient has more than one condition from the K90.4- (Other malabsorption due to intolerance) group of codes, heed the Excludes2 instruction that accompanies the codes. You’ll see that it allows you to code both celiac and non-celiac gluten sensitive enteropathy and lactose intolerance (K90.0, K90.41, and E73.-) together when your gastroenterologist documents them.

Consult these Symptom and History Codes for Support

Symptoms: According to ICD-10-CM Official Guidelines, Section I.B.4, you’ll code the signs and symptoms “when a related definitive diagnosis has not been established (confirmed) by the provider.” You’ll also want to code applicable signs and symptoms to help support medical necessity for any antibody tests the doctor orders or any procedures they perform, such as an esophagogastroduodenoscopy (EGD). Here are some codes for quick reference that might come in handy before your provider is ready to offer a definitive diagnosis:

• R14.0 (Abdominal distension (gaseous))
• R14.3 (Flatulence)
• K59.09 (Other constipation); includes chronic constipation
• K59.1 (Functional Diarrhea)
• R63.4 (Abnormal weight loss)
• R63.5 (Abnormal weight gain)
• D64.9 (Anemia, unspecified)

History: In addition to symptoms that the physician records during the exam, the patient’s personal, family, and social history helps the gastroenterologist assess the likelihood of celiac disease. A complete personal, family, and social history (PFSH) is no longer a requirement for determining an office/outpatient evaluation and management (E/M) level, but these details are still pertinent pieces of the patient’s medical record going forward.

Here are a few codes for quick reference:

• E10- (Type 1 diabetes mellitus)
• L13.0 (Dermatitis herpetiformis)
• E05.- (Thyrotoxicosis hyperthyroidism)
• E03.9 (Hypothyroidism, unspecified)
• K58.- (Irritable bowel syndrome)
• G93.32 (… Chronic fatigue syndrome)
• M79.7 (Fibromyalgia)

Note: A celiac disease diagnosis requires you to report L13.0 and/or G32.81 (Cerebellar ataxia in diseases classified elsewhere) if applicable, per the Use additional note under the code in ICD-10. Pay attention to the Code also note instructing you to report exocrine pancreatic insufficiency (K86.81) if applicable.

Consider This Advice When Leveling the Encounter

A patient presenting with celiac disease might be a very simple encounter or a more complex one, and you’ll select from the regular office/outpatient E/M code set (99202-99215 (Office or other outpatient visit…)).

For example, a young child with diarrhea, a family history of celiac disease, and a positive celiac screening test is a quick and simple assessment and will typically warrant a relatively lower-level visit. On the other hand, 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 moderate or high level based on either medical decision making (MDM) or time.

Chronic or Stable: When using MDM to level a celiac encounter, you may find yourself confused about whether the chronic condition can be considered stable. Currently, a strict, life-long gluten-free diet is the only treatment for celiac disease, which means patient compliance will often determine how stable the condition is.

Let’s first look at how CPT^® describes a patient with a stable chronic illness. Under the definitions for the elements of MDM for E/M services, CPT^® says that “…a patient who is not at his or her treatment goal is not stable, even if the condition has not changed and there is no short-term threat to life or function.” The definition also goes on to note that chronic conditions may not be stable even “if the patient is asymptomatic. The risk of morbidity without treatment is significant.”

In other words, even if the chronic illness is not worsening, it may not be stable. Instead, consider whether you should classify the condition as a chronic illness with exacerbation, progression, or side effects of treatment, which CPT^® defines as “a chronic illness that is acutely worsening, poorly controlled, or progressing with an intent to control progression and requiring additional supportive care or requiring attention to treatment for side effects.” Under the category of the number and complexity of problems addressed element of MDM, a chronic illness with exacerbation, progression, or side effects of treatment should be assigned a moderate level of MDM.

When you consider these definitions — as long as your physician has documented the patient’s treatment goals, that the patient is not meeting those goals, and that the patient needs to do more to achieve those goals— you’re halfway to a moderate level of MDM. Because two of three elements are required to justify any MDM level, if one of the other two MDM elements in the encounter also rises to at least the moderate level, you can go ahead and code 99204/99214 (Office or other outpatient visit for the evaluation and management of a/an new/ established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making …) for this patient encounter.