Gastroenterology Coding Alert

Hint: Hemorrhage and anatomical location still play a role in code selection.

When your clinician diagnoses diverticulosis, you will have a new code for reporting diverticula in both the small and large intestine – an option that was not available when using the ICD-9 system of codes.

ICD-9: When reporting a diagnosis of diverticulosis, you’ll currently have to report from four codes depending on the location and the presence or absence of bleeding (or hemorrhage). So, you’ll report diverticulosis diagnosis using these four codes:

• 562.00 (Diverticulosis of small intestine [without hemorrhage])
  
• 562.02 (Diverticulosis of small intestine with hemorrhage)
  
• 562.10 (Diverticulosis of colon [without hemorrhage])
  
• 562.12 (Diverticulosis of colon with hemorrhage)
  

Caveat: You cannot use these above mentioned codes if your clinician’s diagnosis is congenital diverticulum of colon (751.5); diverticulum of appendix (543.9) or Meckel’s diverticulum (751.0). Also, it is necessary to note that any associated peritonitis should be identified by using an additional code from the range 567.0-567.9.

Note: If the diverticulosis is identified in both the small intestine and the colon, you’ll have to use the individual codes for both the locations and report them appropriately.

ICD-10: When you begin using ICD-10 codes, reporting a diagnosis of diverticulosis will still follow same guidelines as that of anatomical location and presence or absence of bleeding. But, in ICD-10, you have two more codes that help you report a diagnosis of diverticulosis if it is present in both the small intestine and the large intestine. Also, the descriptor to these ICD-10 codes also includes the term “without perforation and abscess” in addition to the location and bleeding parameters to help in distinguishing these codes sets very specifically.

So, the six codes that you have to report a diagnosis of diverticulosis includes:

• K57.10 (Diverticulosis of small intestine without perforation or abscess without bleeding)
  
• 
  
• K57.11 (Diverticulosis of small intestine without perforation or abscess with bleeding)
  
• K57.30 (Diverticulosis of large intestine without perforation or abscess without bleeding)
  
• K57.31 (Diverticulosis of large intestine without perforation or abscess with bleeding)
  
• K57.50 (Diverticulosis of both small and large intestine without perforation or abscess without bleeding)
  
• K57.51 (Diverticulosis of both small and large intestine without perforation or abscess with bleeding)
  

Reminder: As in ICD-9, you cannot use these six ICD-10 codes if your clinician’s diagnosis is congenital diverticulum of small intestine (Q43.8); Meckel’s diverticulum (Q43.0) or diverticulum of the appendix (K38.2).

Focus on These Basics Briefly

Documentation spotlight:Some symptoms that you are most likely to encounter in the documentation of a patient suffering from diverticulosis includes abdominal or epigastric pain; bloating; nausea; vomiting; constipation; melena or hematochezia; flatulence; fever and fatigue. Your clinician will record a complete history including history of any medications that the patient is currently taking.

Upon examination, your clinician might note signs of tenderness on palpating the abdominal area, signs of weight loss, and signs of anemia.

Tests: Some of the tests that your clinician might order include CBC count; hematocrit value; liver function tests; blood culture and urinalysis. Some of these tests will help your clinician eliminate other diagnosis that could be resulting in similar signs and symptoms.

Apart from these lab tests, your gastroenterologist will also order imaging studies such as an abdominal x-ray or a CT scan. Apart from these imaging studies and depending on clinical circumstances your clinician may also perform endoscopic studies such as an upper GI endoscopy or a small intestine endoscopy. If he is suspecting diverticulosis of the colon, he may perform a colonoscopy. Your gastroenterologist might also resort to performing capsule endoscopy to view the GI tract, especially the areas of the small intestine.

Based on the history, symptoms, examination, lab and diagnostic tests, your clinician will arrive at the diagnosis of diverticulosis.

Example: Your gastroenterologist recently reviewed a 55-year-old established male patient with complaints of dark, tarry stools and abdominal pain with bloating. He says that he has also been running fever and has been experiencing some nausea and intermittently been throwing up.

Your gastroenterologist recorded a complete history of the patient including past, family, and social history.

The patient’s current medication list was updated. Upon examination, the patient experienced tenderness on palpation of the abdominal area in the left lower quadrant. Your gastroenterologist also noted paleness of sclera and nails. Your clinician also notes that the patient is looking fatigued and showed signs of weight loss.

Your clinician drew a blood sample and obtained a urine sample and these were sent to the lab for analysis. He also ordered for an abdominal CT scan in which he identified an inflammatory phlegmon in the retroperitoneal space. This finding made him suspect diverticulosis in the small intestine. To confirm this, he decided to perform a double balloon enteroscopy.

The procedure helped your clinician diagnose diverticulosis and identify the source of bleeding and he applied a plasma coagulator to arrest the bleeding. Your clinician also performed a colonoscopy to ascertain that there are no diverticula in the colon.

What to report: You report 44378 (Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, including ileum; with control of bleeding [e.g., injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator]) for the enteroscopy procedure and report 45378 (Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen[s] by brushing or washing, with or without colon decompression [separate procedure]) for the colonoscopy procedure that your clinician performed.

You report the diagnosis with K57.11 if you are using ICD-10 codes or use 562.02 if you are using ICD-9 coding system. You should choose these codes as the diverticulosis (with bleeding) was identified only in the small intestine and not in the colon.