Gastroenterology Coding Alert

Read these case studies and see if you can determine the right ICD-10 codes.

Leafing through the ICD-10 manual can make it appear as though diagnosis coding is incredibly straightforward, but that assumption can be tested when you have an actual chart in front of you. Special circumstances and intricate coding nuances can cause consternation among GI coders, so it’s important to test yourself on occasion to ensure that you know which codes to report.

Check out the following examples and devise a coding solution before you read the appropriate ICD-10 code that applies.

General Abdominal Pain

Scenario: A 37-year-old man presents with abdominal pain. The gastroenterologist notes complaints of generalized abdominal pain for one day, with flatus, no vomiting or diarrhea. Last bowel movement (BM), the same morning, was of hard consistency. Abdomen examination reveals decreased bowel sounds, generalized tenderness to deep palpitation in abdomen. The provider finds there is no localized abdominal tenderness or any palpable masses during the rectal exam.

Coding Solution: Here you may have two options to choose from since the physician didn’t come to a definitive diagnosis. You may code R10.84 to denote generalized abdominal pain, and to depict generalized abdominal tenderness, you may report R10.817 (Generalized abdominal tenderness).

In abdominal pain coding, you will typically encounter only six characters, such as R10.811 (Right upper quadrant abdominal tenderness), found under R10.8 (Other abdominal pain). Typically, ICD-10 coding also depends on whether the patient is being seen for initial encounter or subsequent encounter but this is not the case in abdominal pain coding.

Some payers may give heavier “weight” to a report of tenderness rather than just pain, since this sometimes connotes a more serious cause, so if both are options, opt for R10.817, says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California.  

Barrett’s Esophagus

Scenario: Your gastroenterologist conducts a screening endoscopy on a patient who has been suffering from recurrent and long-standing GERD to check for Barrett’s esophagus. During endoscopy, your gastroenterologist notes changes in the lower esophagus suggestive of Barrett’s esophagus. Your gastroenter­ologist then performs a biopsy and sends the specimen to the laboratory for analysis. The laboratory findings confirm the diagnosis of Barrett’s esophagus with a high grade of dysplasia.

Coding Solution: You’ll report this condition with a code from the K22.7 (Barrett’s Esophagus) section of ICD-10. However, you need to look deeper in the patient notes prior to reporting the diagnosis of Barrett’s esophagus. This is so because ICD-10 codes are specific in reporting Barrett’s esophagus based on the presence or absenceof dysplastic changes. So K22.7 expands into a fourth digit classification based on the presence or absence of dysplastic changes.

• K22.70 --  Barrett’s esophagus without dysplasia
• K22.71 --Barrett’s esophagus with dysplasia

In addition, K22.71 expands to a further fifth digit classification based on the grade of dysplastic changes. So if dysplasia is present, you will have to further look through the documentation to see if there is any mention about the degree of dysplasia that is present to correctly report the diagnosis of Barrett’s esophagus.

• K22.710 -- Barrett’s esophagus with low grade dysplasia
• K22.711 -- Barrett’s esophagus with high grade dysplasia
• K22.719 -- Barrett’s esophagus with dysplasia, unspecified

Therefore, the appropriate code in this scenario is K22.719.

Benign Colon Polyps

Scenario: While performing a screening colonoscopy, the GI finds polyps and treats them. His notes indicate a diagnosis of benign colon polyps, and the notes also mention that the patient has diverticulosis.

Coding Solution: If the physician’s documentation states that the patient presented for screening colonoscopy, you need to have the Z code (such as Z12.11, Encounter for screening for malignant neoplasm of colon) as the first diagnosis even if the physician found and treated other problems. Medicare has been pretty clear that if the patient presents for screening you have to bill the screening with the Z code, even if the physician finds a problem and treats it. By adding a PT modifier to indicate the exam intention was screening, the patient’s deductible is waived for the procedure, but a copay still applies, Littenberg says.

To avoid denials, you should also report the polyp diagnosis code (D12.-, Benign neoplasm of colon, rectum, anus and anal canal) to describe the medical necessity for the service. You should also report diverticulosis (K57.30, Di­verticulosis of large intestine without perforation or abscess without bleeding) since it is noted in the report.

Irritable Bowel Syndrome With Diarrhea

Scenario:  Your physician examines a 52-year-old male new patient with complaints of pain in the abdominal area and flatulence. He also complains of some degree of diarrhea, cramping, and distension, followed by days of constipation. Your clinician performs a thorough evaluation of the patient as well as lab tests and diagnostic testing. Based on history, signs and symptoms, and negative findings from lab tests and imaging studies, your clinician arrives at a diagnosis ofIBS.

Coding Solution: You should report K58.0 (Irritable bowel syndrome with diarrhea) for this situation because the patient not only has IBS, but also suffers from diarrhea.