Gastroenterology Coding Alert

Acute, chronic, hemorrhaging, and more criteria will guide your coding choices.

Gastroenterologists frequently treat ulcers, but even though these conditions are common, coding for them can be confusing. You’ll not only have to clarify the location of the ulcer, but you’ll need to know whether the patient has an acute ulcer or a chronic one. However, that distinction may not be crystal clear.

“Unfortunately, the decision to separate acute from chronic was not made by clinicians, and clinicians can’t readily distinguish acute from chronic for an ulcer, with a few exceptions,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California. “If there is considerable scarring/deformity, or the patient has a long history (or at least more than two to three months) of ulcer symptoms or diagnosis, then the ulcer is reasonably considered to be chronic,” he says. “An ulcer diagnosed a few weeks after a patient starts an NSAID (anti-inflammatory drug) is commonly acute, yet the patient may have had chronic asymptomatic ulcer disease. An ulcer that develops in a critically ill patient with no past history can be considered acute. But if the physician doesn’t specify, you’ll need to use the ‘chronic or unspecified’ series as described below, or ask the physician,” he adds.

Check out the following scenarios to ensure that you can appropriately code ulcers.

Look to the K Series for Ulcers

Scenario 1: The gastroenterologist diagnoses a patient with Bednar’s aphthae. Which diagnosis code applies?

Solution 1: Your first step is understanding what’s involved in Bednar’s aphthae. In this condition, which primarily affects infants, the patient has multiple recurrent ulcers in their mouth. Knowing that information, you’ll look to K12.0 (Recurrent oral aphthae) to report the visit.

When your gastroenterologist suspects a diagnosis of recurrent aphthous ulcer, they will evaluate the patient to understand the frequency of ulcer formation and the size of the lesions. They will also check the patient’s history to understand if there is any family history for the condition, or personal medical history to determine if the patient is suffering from any kind of allergies or vitamin deficiencies. They might also evaluate whether any trauma or medications caused the issue.

In cases where the gastroenterologist identifies an external cause, you can add a secondary ICD-10 code to describe that. However, one is not required to report K12.0 — the code can stand on its own if necessary. Recurrent aphthous ulcers are fairly common in patients with ulcerative colitis or Crohn’s disease, for example, Littenberg says.

Understand Duodenal Ulcer Coding

Scenario 2: A patient presents with burning, sharp pain in their upper abdominal area, and the gastroenterologist diagnoses them, by endoscopy, with a duodenal ulcer. How do you know which code to use?

Solution 2: To select the right duodenal ulcer code, you’ll need to know whether the issue was chronic or acute, and whether an obstruction, hemorrhage, or perforation was present.

When you see the K26 (Duodenal ulcer) category, you’ll notice that a fourth character is required. To pinpoint the most accurate fourth character, you’ll need some detail from the gastroenterologist’s report. If the condition is acute, you’ll look to the K26.0-K26.3 codes (Acute duodenal ulcer…), which are broken down further based on whether the acute duodenal ulcer had hemorrhage, perforation, both, or neither.

If you find that the patient suffers from chronic duodenal ulcers or you don’t have any indication of whether the condition as acute or chronic, you’ll instead need to look at K26.40-K26.7 (Chronic or unspecified duodenal ulcer…) series. These codes also expand further depending on the presence of hemorrhage, perforation, neither, or both.

Finally, your only remaining option is K26.9 (Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation). This code is less specific and you’ll only report it if the gastroenterologist’s record lacks information about whether the ulcer was acute or chronic in nature. In cases of sparse documentation when the physician is unable to add more details, you should turn to this code.