Gastroenterology Coding Alert

You know that a high frequency of Crohn's patients makes these claims important; denials could cost your practice well-earned dollars.

Our experts have broken down Crohn's diagnosis, management and treatment options so that you're never searching for your code again.

Crohn's disease, also called ileitis or regional enteritis, is an inflammatory bowel disease (IBD) that typically irritates the small intestine but can also occur in any part of the digestive tract. Those with Crohn's disease endure frequent pain from intestinal inflammation and often have diarrhea. The patients will find no cure for Crohn's disease, but several treatments are available.

ICD-9 options: When selecting the diagnosis code, you should know which locations in the intestines the physician has identified with Crohn's inflammation. For instance, use 555.0 (Regional enteritis; small intestine) when the inflammation occurs only in the small intestine or ileum. Use 555.1 (... large intestine) when the physician sees only inflammation in the colon (large intestine). If the physician detects Crohn's inflammation in both areas, report 555.2 (... small intestine with large intestine).

There may also be instances when the physician does not specifically mention the areas of inflammation. In those cases, the diagnosis code is 555.9 (... unspecified site).

Watch out: "Make sure you have a definitive diagnosis -- not a suspected or rule-out. Otherwise, you have to go off the symptoms," says Joyce Carpenter, CPC, OGS, MCMC, billing department lead at Internal Medicine Associates LLC in Anchorage, Alaska.

Often a gastroenterologist's first encounter with a Crohn's patient is a consultation. The patient has some sort of gastroenterological problem, and her primary-care physician decides that a gastroenterologist's opinion is needed. "Most of our patients are sent as consults," says Dena Rumisek, biller for Grand River Gastroenterology PC in Grand Rapids, Mich.

- Heads up: Even if another physician diagnoses a patient with Crohn's and she eventually comes under your office's care, the initial meeting with her is a consultation -- as long as the other physician requests the consult.

- If the patient reports initially because her doctor decided that a gastroenterologist's opinion was in order, choose the appropriate code from the outpatient consultation codes 99241-99245 (Office consultation for a new or established patient ...).

- If the gastroenterologist provides a second or third opinion about a patient with Crohn's symptoms, you should assign one of the outpatient office visit codes (99201-99205 for new patients, or 99211-99215 for established patients) or consult codes (99241-99245), whichever is appropriate for your setting and type of service.

Gastroenterologists have several options when testing for Crohn's disease. For instance, they can order simple blood tests to measure for an abnormally high number of white blood cells or a high sedimentation rate, a sign of inflammation somewhere in the body.

FOBT: Physicians may use a guaiac-based fecal-occult test because of its sensitivity to lower-bowel bleeding. The proper CPT code for this test is 82272 (Blood, occult, by peroxidase activity [e.g., guaiac],- qualitative, feces, single specimen [e.g., from digital rectal exam]). Remember: CPT 2008 changed this descriptor to clarify "82272 is appropriately reported for assessment of either a single sample obtained from a digital rectal exam or for assessment of a three-test card prepared by the patient," according to CPT 2008 Changes: An Insider's View.

Colonoscopy: Perhaps the most common way to test for Crohn's is with colonoscopy, during which the physician can check for inflammation or bleeding and take tissue for biopsy. "This is generally our primary choice," Rumisek says. The gastroenterologist will often examine the terminal ileum, and the standard colonoscopy codes include this procedure. You should not report an additional small-bowel enteroscopy with the colonoscopy code. Choose the appropriate code from the colonoscopy group (45378-45387) when your physician uses this diagnosis method.

-- Colonoscopies are a common diagnostic tool because biopsy is possible and the mucosa of the intestines (visible during a colonoscopy) can be a sign of Crohn's in a patient.

Once a gastroenterologist diagnoses Crohn's disease, he chooses among several options for treatment. Changes in diet and lifestyle are always the first steps, along with medication containing the anti-inflammatory agent mesalamine, such as sulfasalazine, Asacol, Dipentum or Pentasa. Another medication option features drugs that suppress the immune system -- such as 6-mercaptopurine and azathioprine -- along with corticosteroids to control inflammation.

The newest class of agents available to treat Crohn's disease are the biologic drugs that interfere with inflammation caused by tissue necrosis factor (TNF). Both Remicade (infliximab) and Humira (adalimumab) are anti-TNF agents. Report these agents using J1745 (Injection, infliximab, 10 mg) for the Remicade and new HCPCS code J0135 (Injection, adalimumab, 20 mg) for Humira.

For the infusion, you would report 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) for the first hour and +96415 (... each additional hour [list separately in addition to code for primary procedure]) for each hour after that.

Partial colectomies and small-bowel resections are occasionally necessary surgeries for Crohn's patients, but often the inflammation returns to the very area from which the intestine was removed. Sometimes the condition is so serious that a total colectomy is needed. If a patient has a partial or total colectomy, report the procedure using the appropriate code from 44140-44160 (Colectomy ...).

- Patients may also require surgery to address symptoms not responding to medical therapy or to correct blockages, perforations, abscesses or intestinal bleeding.