Gastroenterology Coding Alert

Pay more attention to patient documentation to clinch the right location.

When your physician sees a patient with an abscess causing pain in the anorectal region, you're used to reporting this one way in ICD-9. But you'll need the specifics that follow to report the right code when ICD-10 comes into effect on Oct.1, 2014.

Focus on Symptoms and Diagnostic Details in Documentation

Your gastroenterologist will arrive at a diagnosis of anorectal abscess based on findings of history, signs and symptoms, examination, observational findings, imaging studies and laboratory findings. In certain cases, he might resort to other laboratory tests such as blood tests or a urinalysis. Your gastroenterologist might also want imaging studies such as an MRI, CT scan or an ultrasound, especially when the abscess is in the deeper areas of the rectum to arrive at a diagnosis of a rectal abscess.

Some of the symptoms that you are more likely to see in a patient suffering from an anorectal abscess will include pain in the anorectal area, fever (R50.9, Fever, unspecified), pus discharge, swelling in the anorectal area that could possibly be felt like a lump, pain in the lower abdominal area (R10.30, Lower abdominal pain, unspecified), constipation and pain during bowel movements.

When your gastroenterologist arrives at a diagnosis of an abscess in the anal and/or rectal area, you will have to report it with 566 (Abscess of anal and rectal regions) when using ICD-9 codes. You will have to remember that the same code is used irrespective of the location in which you can find the abscess in the anal or the rectal area.

Look Closely into Documentation to Identify Abscess Type

When you begin using ICD-10 codes, 566 in ICD-9 will crosswalk to K61 (Abscess of anal and rectal regions) in ICD-10. Be aware that K61 further expands into five more codes that are based on the location of the abscess in the anal and/or rectal area:

• K61.0 -- Anal abscess -- Don't code abscess of the anal sphincter using this code.
• K 61.1 --Rectal abscess -- Don't code abscess of the ischiorectal fossa using this code.
• K61.2 --Anorectal abscess
• K61.3 --Ischiorectal abscess
• K61.4 --Intrasphincteric abscess

Example: Your gastroenterologist assesses a patient suffering from severe anal pain with pus discharge. He complains of lower abdominal discomfort and severe pain during bowel movements. Upon examination, your gastroenterologist notes a sizeable lump in the anal area with discharge of pus. He orders a blood test and urinalysis to confirm a diagnosis of abscess in the anal region. You report the diagnosis of the abscess with 556 if you are using ICD-9 and K61.0 if you are using ICD-10 codes.