Gastroenterology Coding Alert

Hint: Don’t forget to identify the etiology and report it separately.

When your gastroenterologist diagnoses peritoneal abscess, you should continue to report it in ICD-10 in the same manner that you followed with ICD-9. Pay attention to the other terms that your clinician might use to describe the diagnosis so that you are able to report the condition correctly.

ICD-9: When reporting a diagnosis of peritoneal abscess in ICD-9, you have to use the code, 567.22 (Peritoneal abscess). You report the same ICD-9 code if your clinician’s diagnosis is also any of the following locations for the  abscess:

• abdominopelvic
• mesenteric
• omentum
• peritoneum
• retrocecal
• subdiaphragmatic
• subhepatic
• subphrenic

Caveat: You cannot use 567.22 if your clinician’s diagnosis is peritonitis. In such a case scenario, you will have to choose other ICD-9 codes depending on the type of peritonitis that your clinician identifies. For example, if your clinician notes the diagnosis as benign paroxysmal peritonitis, you will report the diagnoses with 277.31 and not 567.22. Similarly, a diagnosis of acute appendicitis with generalized peritonitis will have to be reported with 540.0.

ICD-10: When you begin using ICD-10 codes, a diagnosis of peritoneal abscess that you report using 567.22 in ICD-9 crosswalks to K65.1 (Peritoneal abscess). This is a straightforward transition with not many changes in the way you used to report this diagnosis with ICD-9 codes. As in ICD-9, you apply the same diagnosis code if your clinician notes the diagnosis as abdominopelvic abscess, abscess of omentum, abscess of peritoneum, mesenteric abscess, retrocecal abscess, subdiaphragmatic abscess, subhepatic abscess, and subphrenic abscess.

Code additionally:The condition is often caused by a ruptured appendix, ruptured intestinal diverticulum, inflammatory bowel disease, or parasitic infection in the intestines. You should also code those conditions, if documented. If the condition has resulted due to infection, you will have to identify the infectious agent with the ICD-10 codes, B-95-B97.

Check These Basics Briefly

Documentation spotlight: Some of the symptoms that you will normally come across when your clinician identifies the diagnosis as peritoneal abscess will include pain in the abdomen, loss of appetite, fever, and weight loss. Upon examination, your clinician might note focal tenderness and tachycardia.

Tests: Your clinician might ask for certain lab tests if he suspects an abscess. He will withdraw blood for CBC and other blood tests. He might also order for a blood culture if he suspects the abscess to be caused due to an infection.

Some of the diagnostic tests that your gastroenterologist might also order include an abdominal x-ray, ultrasound or a CT scan of the abdominal area. If the imaging studies shows the presence of an abscess, you clinician might then perform a paracentesis or a peritoneal lavage to help confirm the diagnosis of a peritoneal abscess.

Example: Your gastroenterologist reviews a 45-year-old male patient for pain and swelling in the right abdominal area. The patient also complains of sudden weight loss and loss of appetite over the past few days. The patient has a history of Crohn’s disease.

Upon examination, your clinician makes note of tenderness over the affected area. He also notes that the patient is febrile and appears to be fatigued and disoriented. He orders for a CT scan of the area and draws blood that he sends to the lab for analysis. Based on the results of the scan and the lab tests, your clinician confirms the presence of an abscess. He then performs a percutaneous drainage of the abscess using imaging guidance and drains the abscess.

What to report: You can report the evaluation of the patient using 99213 (Office or other outpatient visit for the evaluation and management of an established patient…) depending on the visit documentation. You report the drainage procedure with 49020 (Drainage of peritoneal abscess or localized peritonitis, exclusive of appendiceal abscess; open) and 75989 for the radiological guidance.