Gastroenterology Coding Alert

Presence or absence of diarrhea aids in diagnosis selection.

Your gastroenterologist might see patients with abdominal pain regularly. Abdominal pain can result from a variety of conditions, one such being irritable bowel syndrome (IBS), so knowing how to report this diagnosis with ICD-10 codes will definitely ease your coding challenges when the new code set comes into effect.

Review These Details in Documentation

Your gastroenterologist will usually eliminate the possibility of other conditions to arrive at the diagnosis of irritable bowel syndrome. Your gastroenterologist will only be able to arrive at a final diagnosis of irritable bowel syndrome based on findings of history, examination, observational findings during colonoscopy, imaging studies and laboratory findings.

Some symptoms that will trigger your gastroenterologist to suspect irritable bowel syndrome include abdominal cramping and discomfort (R10.9, Unspecified abdominal pain); flatulence (R14.3, Flatulence); bloating and abdominal distension (R14.0, Abdominal distension [gaseous]); episodes of diarrhea (R19.7, Diarrhea, unspecified) and constipation (K59.0, Constipation) and changes to bowel habits (R19.4, Change in bowel habit).

When your gastroenterologist suspects a diagnosis of irritable bowel syndrome, he will order for imaging studies such as a CT scan or an x-ray of the small intestine. He might also conduct blood tests and stool tests to rule out the possibility of other conditions with similar symptoms. Your gastroenterologist will also undertake a colonoscopy (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]) to aid the diagnosis of the condition.

Note the Use of Same Code in ICD-9

When you report a diagnosis of irritable bowel syndrome using ICD-9 codes, you do not have to check specifically for the presence or absence of diarrhea, as all the types of the condition is reported using the same code. If your gastroenterologist diagnoses irritable bowel syndrome, you will have to use 564.1 (Irritable bowel syndrome) if you are using ICD-9 codes to report the condition.

You have to note that the same code can be used if your gastroenterologist diagnoses spastic colon or an irritable colon.

Get Specific About Diarrhea in ICD-10

With ICD-10 codes, you will have to look specifically for the presence or absence of diarrhea, as this will affect the way you report a diagnosis of IBS.

When you start using ICD-10 codes, 564.1 transforms into the child code K58 (Irritable bowel syndrome). However, K58 further expands into two different codes depending on the presence or absence of symptoms of diarrhea:

• K58.0 -- Irritable bowel syndrome with diarrhea
• K58.9 -- Irritable bowel syndrome without diarrhea. This code is also used if presence or absence of diarrhea is not specified.

You can also use the above mentioned ICD-10 codes (depending on presence or absence of diarrhea) when your gastroenterologist arrives at a diagnosis of spastic colon or irritable colon.

Example: A 56-year-old female patient arrives at your gastroenterologist's office with complaints of severe abdominal cramping and pain. She complains that she has been having these symptoms from quite some time and it has started aggravating her to a point that she is not comfortable. She also complains of frequent episodes of diarrhea for some days followed by episodes of constipation for another couple of days. Upon being questioned, she also specifies that her bowel habits have changed over the period of a year or so and she fears stepping away for long from her house and this has been affecting her work and social life.››››

Your gastroenterologist conducts a comprehensive evaluation of the patient. Based on the history and symptoms present, he suspects IBS and orders blood tests, stool tests and imaging studies (CT and abdominal ultrasound) to rule out other conditions that mimic the symptoms of inflammatory bowel syndrome. He also performs a colonoscopy (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]) to rule out other conditions such as ulcers and inflammatory bowel disease.

Since the findings of the tests weren't significant to diagnose any other condition and symptoms pointing in the direction of IBS, your gastroenterologist arrives at the diagnosis of the condition. Since the patient experienced symptoms of diarrhea, you will have to report the diagnosis with K58.0.