Gastroenterology Coding Alert

Look beyond location to arrive at the right codes.

Ulcerative colitis is a form of inflammatory bowel disease that you will commonly see in your gastroenterologist's practice, so you'll need to understand how to report it using ICD-10 codes when they come into effect. Paying attention to the presence or absence of complications associated with ulcerative colitis is your key to appropriately reporting the condition.

Review the Notes for These Details

You will need to know what symptoms might trigger your gastroenterologist to suspect a diagnosis of ulcerative colitis. However, a final diagnosis can only be ascertained after suitable blood tests and observational findings during endoscopy.

Symptoms of ulcerative colitis can include chronic diarrhea (R19.7, Diarrhea, unspecified), rectal bleeding, fecal urgency (R15.2, Fecal urgency), lower abdominal cramps (R10.9, Unspecified abdominal pain), blood in stool (K92.1, Melena), and weight loss.

Your gastroenterologist may review tests such as complete blood counts, ESR, stool specimens, liver function tests, and c-reactive protein to arrive at a diagnosis of ulcerative colitis.

Your gastroenterologist will also perform diagnostic procedures such as a proctosigmoidoscopy (45300, Proctosigmoidoscopy, rigid; diagnostic, with or without collection of specimen[s] by brushing or washing [separate procedure]), sigmoidoscopy (45330, Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen[s] by brushing or washing[separate procedure]), 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]) or colonoscopy with biopsy (45380, Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) to confirm the diagnosis of ulcerative colitis. During these procedures, your gastroenterologist will determine the extent of the problem and will also check the presence (or absence) of complications such as obstruction, fistula, bleeding or any type of abscess.

Reporting Ulcerative Colitis in ICD-9

Under ICD-9, ulcerative colitis is reported with 556.x. The fourth digit specifies the location of the pathology. In ICD-9, 556.x expands to nine codes depending on location. In ICD-9, you do not pay heed to the presence of complications when you report the condition.

Observe Location Guidance and Complications

When ICD-10 comes into effect, the location of the lesion will determine your code choice as in ICD-9. In addition to the location, you need to look for the presence of complications such as rectal bleeding, intestinal obstruction, fistula, and abscesses as the code for ulcerative colitis in ICD-10 is further expanded to the fifth digit depending on the presence of these specified or unspecified complications.

Example 1: Your gastroenterologist conducts a sigmoidoscopy to confirm a diagnosis of suspected chronic rectosigmoiditis. Your gastroenterologist also documents the presence of rectal bleeding. Under ICD-9, you will report the diagnosis with 556.3 (Ulcerative [chronic] proctosigmoiditis). Note that complications are not in the descriptor in ICD-9. Under ICD-10, you will turn to code K51.311 (Ulcerative [chronic] rectosigmoiditis with rectal bleeding).

Example 2: In the procedure notes, you read that your gastroenterologist conducted a colonoscopy to confirm a diagnosis of inflammatory polyps of the colon. Additionally, your gastroenterologist also notes the presence of an abscess. You will report this condition with 556.4 (Pseudopolyposis of colon) under ICD-9. When you are reporting the same condition with ICD-10, you will report K51.414 (Inflammatory polyps of colon with abscess).

Example 3: If you read in the note that, based on results of tests and observations found in the colonoscopy, your gastroenterologist arrived at a diagnosis of pancolitis. During the procedure, no other complications of significance were noted, so you report the diagnosis with 556.6 (Universal ulcerative [chronic] colitis) under ICD-9. However, under ICD-10, you will have to report the condition using K51.00 (Ulcerative [chronic] pancolitis without complications).

Editor's Note: For charts that crosswalk ICD-9 and ICD-10 codes for Ulcerative colitis, please email the editor, SachinThimmaiah, sthimmaiah@codinginstitute.com