Gastroenterology Coding Alert

ICD-9 564.0x should describe constipation, but don't forget to report comorbid conditions, too.

Not all enemas are imaging procedures. Sometimes the gastroenterologist will opt to administer an enema to treat constipation. Your challenge in such cases is whether to include the enema tubing in an E/M or bill it as a separate procedure. Use the following situation -- plus the bonus tips -- to help you with accurate coding.

Scenario: Our nursing staff administered an enema for an elderly gentleman due to severe constipation after an office visit with his physician. The patient has history of encopresis and constipation. What code choices do you have?

Say No To Imaging Services 74283, 74270

Seeing the word 'enema' can sometimes mislead you to consider 74283 (Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction [e.g., meconium ileus]), but you should stop right there.

Why: Don't report 74283 because this code wouldn't be appropriate for this particular scenario. CPT® 74283 falls under the "Diagnostic Radiology (Diagnostic Imaging) Procedures of the Gastrointestinal Tract" section of your manual, and is classified as a radiology service. You would use 74283 for imaging enhancement (e.g., barium enema), which has nothing to do with what we think of as a therapeutic enema in the physician's office.

Nor is 74270 (Radiologic examination, colon; contrast [example, barium enema, with or without KUB]) the appropriate code, in case you were thinking of that one instead.

Why it's still the wrong report 74270: Like 74283, this code describes a radiology exam for viewing the intestine. The procedure utilizes a suspension of barium sulfate, a chalk-like substance that appears white on the x-ray, to delineate the lining of the colon and rectum. During this procedure, the provider administers the barium via the rectum and is held inside the colon while he takes x-rays of the patient's intestine.

Integrate Therapeutic Enema Into Your E/M

Enema administration may also be performed therapeutically in order to relieve intussusceptions or intestinal obstructions. When the provider injects liquid through the anal canal, fluid soaks and loosens hardened waste matter lying in the patient's colon.

Enema for removal of impacted feces is not reported separately and is included when an E/M code is reported, says Melanie R. Daugherty, CPC, CPC-H, CPC-P, coder, Ambulatory Procedure Department Naval Medical Center Portsmouth, Portsmouth, Virginia.

Since this is the case with the given scenario, you would likely use any of the E/M established outpatient visit codes 99213-99215 to describe the E/M and the rest of the procedure -- including the administration of enema.

Hint: The higher code level would be reasonable, given the medical decision complexity weighing therapeutic options, hospitalization risks, and comorbidities.

There is also an add-on code for E/M visits for prolonged service time that does not require direct patient face-to-face contact, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C., and former member of the AMA's CPT Advisory Panel.

"Someone might also think that they can bill 99358 (Prolonged evaluation and management service before and/or after direct [face-to-face] patient care; first hour) or +99359 (Prolonged evaluation and management service before and/or after direct [face-to-face] patient care; each additional 30 minutes [List separately in addition to code for prolonged physician service]). However, Medicare contractors will not pay (nor can providers bill the patient) for these prolonged services codes. These are Medicare covered services and reimbursement is included in the payment for other billable E/M services," Weinstein explains.

Append correct dx: As for the appropriate ICD-9 code, you should report 564.00 (Unspecified constipation) as the primary diagnosis, and 789.0x (Abdominal pain) as secondary diagnosis to describe pain from the stomach or another of the patient's comorbid conditions.