Gastroenterology Coding Alert

Understand Normal Diagnostic Results

Question 1: The gastroenterologist refers a patient to a radiologist for an abdominal CT scan with a symptom of abdominal pain. The CT scan, when interpreted by the GI physician, reveals the presence of an abscess. Both the radiologist — when reporting for the technical component of the CT scan, and the gastroenterologist — when reporting for the follow-up E/M visit for the same test, should report a diagnosis of “intra-abdominal abscess” (K65.1, Peritoneal abscess). However, what should you do if the diagnostics had come out normal?

Answer 1: If the diagnostic test does not provide a definitive diagnosis or if it came out with normal results, you should code the sign or symptom that prompted the treating physician to order the study. Say, in the previous scenario, the CT scan results came back without any abnormal findings, then you would report the symptom (the abdominal pain) instead of K65.1.

If the diagnostic test was normal, but the referring physician records a suspected (a.k.a. probable, suspected, questionable, rule out, or working) diagnosis, you should not code the referring diagnosis. Instead, you should again report the presenting signs and symptoms. The ICD-10-CM guidelines warn, “The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.” For instance, suppose the physician’s notes indicated “suspected blockage of a bile duct by gallstones,” but the CT scan came out normal. Again, you would report the symptom (R10.9) rather than the suspected condition as the reason for the test.

Keep in mind: If the patient is receiving only diagnostic services during the outpatient visit, you would list first the condition that is the main reason for the visit on the claim. This code should be your primary diagnosis. Then, code for other diagnoses (such as chronic conditions) on the following lines. For example, say a patient with chronic gastritis got the CT scan, and test results revealed the presence of a peritoneal abscess. On your claim you should list K65.1 as your primary diagnosis and K29.40 (Chronic atrophic gastritis without bleeding) as your secondary diagnosis.

Remember: “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification,” state the 2022 ICD-10-CM Official Guidelines for Coding and Reporting, which went into effect on October 1, 2021. “Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present,” the guidelines note.

2. Know How to Code Duodenal Ulcers

Question 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?

Answer 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 was acute or chronic, you’ll instead need to look at the K26.4-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.

3. Elucidate Cause of Abdominal Pain When Possible

Question 3: A 25-year-old man presents with abdominal pain. The physician 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 palpation in abdomen. The provider finds there is no localized abdominal tenderness or any palpable masses during the rectal exam. Which code applies?

Answer 3: Here you may have two options to choose from. You may code R10.84 (Generalized abdominal pain) to denote generalized abdominal pain, and to depict generalized abdominal tenderness, you may report R10.817 (Generalized abdominal tenderness).

Don’t forget: Abdominal pain is probably the most common complaint a gastroenterologist sees, and refers to any pain in the region between the chest and groin. The location, severity, and extent of the pain are crucial aspects for a provider’s clinical decision making, as well as deciding on an appropriate code. ICD-10 coding is very specific, noting that abdominal pain is found under chapter 18 of ICD-10, in category R10 (Abdominal and pelvic pain…). ICD-10 coding depends on the site, etiology and manifestation or state of the disease or condition.

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 could usually be due to a stomach virus, indigestion, or gas. In other cases, kidney stones and gallstones could give rise to colic pain. Communicate with your providers in order to get them to document appropriately if you see frequent mentions of “abdominal pain” with no further detail.

You can explore the range of codes available in the R10.- (Abdominal and pelvic pain…) category, and use them judiciously to pinpoint the most appropriate code for the symptom. When pain complaints are in more than one region, then using more than one code may be appropriate.

Code pain in upper abdomen with R10.1-: Within the R10.- category, the subcategory R10.1- (Pain localized to upper abdomen) has codes that refer to pain arising from upper abdomen:

• R10.10 (Upper abdominal pain, unspecified)
• R10.11 (Right upper quadrant pain)
• R10.12 (Left upper quadrant pain)
• R10.13 (Epigastric pain) dyspepsia, excludes1 functional dyspepsia (K30.-)

Code pain in lower abdomen with R10.3-: Similarly, the subcategory R10.3- (Pain localized to other parts of lower abdomen) has codes that refer to pain arising from lower abdomen:

• R10.30 (Lower abdominal pain, unspecified)
• R10.31 (Right lower quadrant pain)
• R10.32 (Left lower quadrant pain)
• R10.33 (Periumbilical pain).

There is one other category (R10.8-, Other abdominal pain) where the fourth digit expands from one to four.

• R10.81- (…Abdominal tenderness)
• R10.82 (Rebound abdominal tenderness)
• R10.83- (…Colic)
• R10.84 (Generalized abdominal pain).

Codes R10.81 and R10.83 further expand into the sixth digits 0-7 and 9 to add more specificity and give more power to the physician to pinpoint the diagnosis. The expansions for both codes go as:

• 1 (Right upper quadrant)
• 2 (Left upper quadrant)
• 3 (Right lower quadrant)
• 4 (Left lower quadrant)
• 5 (Periumbilical)
• 6 (Epigastric)
• 7 (Generalized)
• 9 (Unspecified site).

Final takeaway: In abdominal pain coding, you will encounter only six characters, such as R10.811 (Right upper quadrant abdominal tenderness), found under R10.8 (Other abdominal pain). Therefore, 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. Also code for underlying factors, such as vomiting and nausea as well as rebound abdominal tenderness if applicable.