Gastroenterology Coding Alert

Hint: You’ll want to document your E/M services thoroughly for these visits.

Although some enemas constitute imaging procedures, that’s not always the case. In certain situations, the gastroenterologist will administer an enema to treat constipation. The coder’s challenge in such cases is whether to include the enema as part of the E/M service or bill it as a separate procedure. Use the following tips to help you accurately code these services.

Scenario: The nursing staff administers an enema for an 82-year-old male patient 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?

Avoid 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 (eg, 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^® code 74283 falls under the “Diagnostic Radiology (Diagnostic Imaging) Procedures of the Gastrointestinal Tract” section of your code book and is classified as a radiology service. You would use 74283 for imaging enhancement (such as a barium enema), which has nothing to do with what we think of as a therapeutic enema in the physician’s office.

And although some coders instead turn to 74270 (Radiologic examination, colon, including scout abdominal radiograph(s) and delayed image(s), when performed; single-contrast (eg, barium) study), this is also not the appropriate code for this situation.

Here’s why: 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 it is held inside the colon while they take X-rays of the patient’s intestine.

Integrate Therapeutic Enema Into Your E/M

Enema administration may also be performed therapeutically 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.

Here’s how to code it: Enema for removal of impacted feces is not reported separately and is included in the E/M code for a particular date of service. Although this will typically come from the 99201-99215 range, you’ll select the specific code based on the documentation of the encounter.

Append correct dx: As for the ICD-10 code, you should report the appropriate constipation code (such as K59.00, Constipation, unspecified) as the primary diagnosis for this scenario, followed by any additional diagnoses that may exist.

When it comes to the enema cost, you can ask the patient to purchase what’s needed and bring it to the office, if you arrange it ahead of time, says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California. “Or, if the patient is informed ahead of time, the cost can be charged as a noncovered item separate from the visit,” he notes. “Gastroenterology offices ordinarily do not have the ability to bill durable medical equipment and supplies to payers.”