Gastroenterology Coding Alert

Challenge yourself — and enter 2020 with a bang.

As 2019 comes to a close and we prepare to ring in the new year, it’s a good time to check up and make sure you’re entering 2020 with the sharpest coding skills possible.

Check out the following GI-specific coding quiz questions and determine whether you can select the right codes for these scenarios before reading the solution.

Scour the Documentation for Eating Disorder Codes

Question 1: A 17-year-old new patient presents complaining of stomach pain and says she can’t explain when it started or what may be causing it. She describes her appetite and eating habits as normal, but she weighs just 86 pounds and is 5’9” tall. The gastroenterologist examines the patient and diagnoses her with an eating disorder. Which diagnosis codes apply to this case?

Solution: For this one, you’ll probably need to dig deeper into the documentation to see if there are any more details about the patient’s eating disorder, since the specific disorders are coded using unique ICD-10 codes. Your options will probably fall within the following categories:

• Anorexia nervosa: You’ll find two main code sets for anorexia: F50.0- (Anorexia nervosa) and R63.0 (Anorexia). Distinguishing between the two, however, is easy once you remember that the code for anorexia nervosa belongs in the Mental, Behavioral and Neurodevelopmental Disorders chapter of ICD-10, whereas R63.0 is a signs and symptoms code. This means it does not represent a patient with a psychological eating disorder. In fact, R63.0 is used for an unexplained or unknown loss of appetite. To reflect the fact that the two conditions have different etiologies, ICD-10 guidelines make R63.0 an Excludes1 code for all the F50 (Eating disorder) codes and make F50.0- an Excludes1 code for R63.0. In other words, the excludes notes for both sets of Chapter 5 and 18 codes direct you to one chapter or the other, not both. Therefore, if the physician believes the patient is suffering from anorexia, get a clear picture from the GI on whether the patient has anorexia or anorexia nervosa before selecting a code.
• Bulimia nervosa: A patient with bulimia is a compulsive eater who binges and then purges, which means the patient is self-inducing vomiting or is misusing laxatives, diuretics, or enemas. Additionally, a provider may also diagnose a type of anorexia that features binging and purging. This means you have three different codes to choose from that feature very similar conditions: F50.2 (Bulimia nervosa), F50.81 (Binge eating disorder), and F50.02 (Anorexia nervosa, binge eating/purging type). The key to distinguishing between F50.2, F50.81, and F50.02 can often lie in the patient’s weight. While F50.2 involves compulsive binge eating and purging, many patients remain at a normal weight. However, F50.81 represents an eating disorder that involves binge eating without purging, resulting in many patients being overweight. And F50.02 is similar to F50.2 in that it involves binging and purging, but patients are often extremely underweight and will exhibit other symptoms of anorexia nervosa, such as excessive exercising and long stretches without eating.
• Other eating disorders: If your patient doesn’t fall into either of these categories, you have several other options, such as R63 (Symptoms and signs concerning food and fluid intake), R63.2 (Polyphagia) or excessive eating, and R63.3 (Feeding difficulties). In addition, you can also consider such codes as R63.4 (Abnormal weight loss) or R63.6 (Underweight), depending on the documentation of the physician’s assessment.

In addition, there’s another disorder that you may not have heard of that you need to know. “A newer disorder distinct from other eating disorders is termed ‘Avoidant/restrictive food intake disorder,’ (F50.82) where individuals who seems to have irritable bowel like symptoms but have restricted food types so extremely that they become seriously underweight yet have normal body image, unlike anorexia nervosa,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California.

Can You Bill Vaccine Administration With Other Services?

Question 2: An established 66-year-old patient presents for an E/M service to check on her Crohn’s disease. The patient says that she has not seen another doctor since she visited your GI practice the same time last year. The gastroenterologist asks if she’s interested in a flu shot and she says yes. Which immunization administration code applies?

Solution: Flu shot codes can be tricky, particularly since many of the administration codes are dependent on the patient’s age at the time of the injection.

In this case, the most appropriate code is probably 90662 (Influenza virus vaccine (IIV), split virus, preservative free, enhanced immunogenicity via increased antigen content, for intramuscular use). Although this code does not specify an age range, this service is usually only covered by payers when the patient is age 65 or older.

This is because 90662 describes a high-dose variant of the vaccine (as the words “enhanced” and “increased antigen content” in the descriptor indicate this), which the Food and Drug Administration (FDA) regard as being more appropriate for older patients. Because of that, Medicare and payers that follow its guidelines will not typically cover 90662 for beneficiaries under the age of 65.

As a reminder, CPT^® guidelines recommend you “refer to the product’s prescribing information for the licensed age indication before administering a vaccine to a patient.” You can also consult the Immunization Action Coalition’s chart, which correlates vaccines with their appropriate age group and CPT^®/HCPCS code, at  http://www.immunize.org/catg.d/p4072.pdf.

Don’t forget: You can also report the appropriate established patient E/M code that applies to the service (99211-99215). Although the National Correct Coding Initiative (NCCI) doesn’t have any edits that preclude you from reporting the E/M code and the vaccine administration code at the same time, many payers will still require you to attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M code if the vaccine administration occurs on the same date of service.

Look to C Series for Esophageal Cancer

Question 3: The gastroenterologist sees an established patient who presents following a biopsy the week prior.The GI reviews the pathology report and diagnoses the patient with a malignant lesion in the “abdominal esophagus.” Which diagnosis code applies to this condition?

Solution: The correct diagnosis code for this uncommonly seen condition is C15.5 (Malignant neoplasm of lower third of esophagus). ICD-10-CM provides three codes for esophageal malignancy: C15.3 (Malignant neoplasm of upper third of esophagus), C15.4 (Malignant neoplasm of middle third of esophagus), and C15.5.  A closely related code is C16.0 (Malignant neoplasm of cardia), which is the gastric side of the esophagogastric junction, Littenberg adds.

You might see sections of the esophagus referred to as cervical esophagus, thoracic esophagus, and abdominal esophagus. These terms are roughly equivalent to the ICD-10-CM terminology that divides the esophagus into thirds.