Gastroenterology Coding Alert

Be able to tell when to label an E/M service as extended ROS.

If you think celiac disease routinely classifies as gastroenterological disease, you are wrong. In fact, atypical celiac disease presents with few or even no GI signs or symptoms. If you're not keen enough to spot the telling factors of celiac, your claim is bound to suffer. Uncover the enigma of coding this disease with these guidelines.

Background: Most primary care physicians (PCP) would offer serological screening for celiac disease for patients with a family history of celiac disease or unexplained anemia or iron deficiency, recurrent abdominal pain or bloating, irritable bowel syndrome (IBS), chronic fatigue, unexplained liver enzyme abnormalities, or an autoimmune disease. Those with a positive result would then be referred to a gastroenterologist for duodenal biopsy.

Match 44361, 43239 With Procedure Based On Biopsy Method

Celiac disease (579.0) is a digestive condition that relates to an intolerance of gluten, which is primarily found in bread, pasta, cookies, pizza crust and many other foods containing wheat, barley or rye. It damages the small intestine and interferes with absorption of nutrients from food. Since symptoms are not always gastrointestinal, you should be familiar with counting history of present illness; personal, family, and social history; and review of systems elements to code the E/M aspect of celiac.

For example, a patient who presents with symptoms and history suggestive of celiac disease undergoes a long, complex evaluation requiring intensive workup. This would meet criteria for a high level of E/M coding. On the other hand, a straightforward case of a child with family history of celiac, diarrhea, and a positive celiac screening exam would warrant only a low level E/M code, explains Stefano Guandalini, MD, professor of pediatrics and gastroenterology section chief at the University of Chicago's Comer Children's Hospital.

Diagnostics: The physician could order a blood test for high levels of anti-tissue transglutaminase antibodies. He may also perform a biopsy of the small intestine, which you would code with 44361 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with biopsy, single or multiple), if she used a pediatric colonoscope or dedicated push enteroscope; or 43239 (Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with biopsy, single or multiple), if she performed a complete esophagogastroduodenoscopy (EGD).

Caution: You should report 44361 or 43239 only once no matter how many biopsies your physician takes. You would also never report both codes on the same claim because 43239 is a component of the more invasive 44361 procedure.

Don't Miss Out On Important E/M Components

During E/M for celiac disease, the physician determines the patient's ROS (review of systems) level. When the physician examines two to nine of the patient's systems, you would label it as an extended ROS (a component of a detailed history). Meanwhile, if she looks at 10 or more systems, it's called a complete ROS, which is required for the patient's comprehensive history.

For instance, the physician may look at the following symptoms present in a celiac patient, and be able to identify the ROS level:

• Chronic diarrhea or constipation or both (gastrointestinal);
• Pale, foul-smelling stool (gastrointestinal);
• Bone or joint pain (musculoskeletal);
• Weight loss (constitutional);
• Delayed growth or onset of puberty (endocrine);
• Infertility (reproductive);
• Tooth discoloration or loss of enamel (ENT);
• Depression/irritability (psychiatry);
• Unexplained anemia (circulatory); and
• Lack of energy/fatigue (constitutional).

E/M also requires the physician to evaluate the patient's history of present illness (HPI) and personal, family, and social history (PFSH). HPI is a chronological description of the patient's current illness. The physician would note factors such as location (example: abdomen), quality (example: nausea), severity (example: limited disease process), duration, timing (example: mornings), context (example: after meals), modifying factors (example: better with change in diet), and associated signs and symptoms (example: fatigue) to determine the HPI type. If she documents one to three of these factors, you would consider it a brief HPI. Four or more of these elements means an extended HPI.

Lastly, the patient undergoes a review of his PFSH to help the physician diagnose celiac disease. A complete PFSH documents two or three of the history areas. Personal and family history items may include:

• Type 1 diabetes;
• Dermatitis herpetiformis;
• Thyroid disease;
• Sjögren's syndrome; and
• Eczema.