Gastroenterology Coding Alert

See whether pediatric stomach pain is coded differently.

When it comes to stomach issues, patients can experience a lot of different symptoms, and providers can document a lot of terms and codes for the different stomach ailments. All of these terms, as well as the correct coding for the conditions, can get confusing to gastroenterology coders.

Here are four frequently asked questions (FAQs) pertaining to different abdominal issues that you might also be wondering about. Keep reading, and you may find answers you’re looking for.

Question 1: What is the difference between inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), and colitis?

Answer: Patients often see GI specialists for conditions like IBD and IBS, and often they’ve been referred to by their primary care practitioner (PCP). That means there could be a lot of information in the medical record that is hard to sift through. When it comes to these two terms, it’s helpful to know the following information.

IBD is a general term that encompasses conditions involving immune response and inflammation of the GI tract, such as Crohn’s disease and ulcerative colitis. IBD is not to be confused with IBS, however. Where IBD is an autoimmune condition, IBS is a functional disorder, meaning it causes symptoms but doesn’t cause visible inflammation or actual damage to the digestive tract. Also, IBD diagnoses generally require imaging or colonoscopies, whereas a physician can generally diagnose IBS based on symptoms and the exclusion of other conditions.

Colitis is another term that gets thrown around a lot. It’s a digestive disease that causes inflammation in the large intestine. Colitis is a type of inflammation in the colon, which you might code to K52.9 (Noninfective gastroenteritis and colitis, unspecified), whereas IBD is a group of conditions, including Crohn’s and ulcerative colitis. Some examples of IBD codes include K50.0- (Crohn’s disease of small intestine) and K51.30 (Ulcerative (chronic) rectosigmoiditis without complications).

Question 2: Our doctor saw a 35-year-old patient who was complaining of stomach pain that had lasted about 24 hours, flatulence, constipation, and the provider noted generalized tenderness to deep palpation. There’s no diagnosis, however. Which diagnosis codes should I report?

Answer: There won’t always be a diagnosis. In fact, with stomach issues, there often isn’t a diagnosis, just symptoms. And even when there is a diagnosis, it often took several visits for the physician to gather enough information to make that diagnosis.

Even though there aren’t many specifics in this particular case, there are still a couple of applicable codes you can use. You can code R10.84 (Generalized abdominal pain) to account for the generalized stomach pain. For the tenderness, you can report R10.817 (Generalized abdominal tenderness).

Note: Abdominal pain is one of the most common complaints heard from patients. Abdominal pain refers to any pain between the chest and groin, and there are a lot of different organs in there. Therefore, the more specific the provider can get about location and severity of pain will not only help their own clinical decision making, but it will help you code to the highest specificity.

For example, pain concentrated in a particular area that starts suddenly and unexpectedly could indicate a problematic appendix or gallbladder. A pain that manifests as a generalized pain in the belly is usually due to a stomach virus, indigestion, or gas. In other cases, kidney stones and gallstones could give rise to colic pain.

If you see frequent mentions of “abdominal pain” with no further detail, communicate with your providers to help them understand the extent of the R10 code set so they can better see the value in documenting more exact symptoms.

Question 3: Should I code constipation differently if it’s a diagnosis rather than just a symptom?

Answer: How you code constipation depends on the circumstances, and the coding may be different if the condition is a symptom versus a diagnosis. Let’s break it down a bit.

Symptoms: A gastroenterologist might determine a patient is constipated based on symptoms, but that might not be the best ICD-10 code to report for that encounter. For example, if a patient explains they have not had a bowel movement in five days and is feeling bloated, gassy, and nauseated, this can get tricky. Constipation, even if documented, certainly seems like the obvious diagnosis, but it’s not as simple as that.