Gastroenterology Coding Alert

Hint: Don’t forget to check documentation for additional complications.

When reporting a diagnosis of portal hypertension using ICD-10, you will need to report it with the simple crossover ICD-10 code K76.6. However, as in ICD-9, you will also need to report any complications such as portal hypertensive gastropathy with an additional code.

ICD-9: Under ICD-9, you will have to report a diagnosis of portal hypertension with 572.3 (Portal hypertension). Although portal hypertension is mainly a complication of liver cirrhosis (571.2, Alcoholic cirrhosis of liver), it could also be caused due to other non-cirrhotic etiologies. 

When your clinician arrives at this diagnosis, you should look for other complications such as portal hypertensive gastropathy. If your gastroenterologist identifies this complication, you should report it separately with 537.89.

ICD-10: When you begin using the ICD-10 set of codes, portal hypertension that you report with 572.3 in ICD-9 crosswalks to K76.6 (Portal hypertension). Again, as in ICD-9, you will have to report any associated complications such as portal hypertensive gastropathy with a separate code. In ICD-10, you report this complication using K31.89.

Reminder: Under ICD-10 code sets, you will have to also use an additional code to help identify alcohol abuse and dependence (F10.-). The list of exclusions will comprise jaundice NOS (R17), hemochromatosis (E83.11-), Reye’s syndrome (G93.7), viral hepatitis (B15 – B19) and Wilson’s disease (E83.0).

Focus on These Basics Briefly

Documentation spotlight:Some of the signs and symptoms that you are most likely to see in the documentation of a patient with portal hypertension will include fever, weakness, nausea, vomiting, abdominal pain, weight loss, anorexia, sudden bleeding, ascites, signs of jaundice, muscle cramps, dark stools and changes to mental well being.

Upon examination, your gastroenterologist might note signs of anemia, jaundice, ascites, splenomegaly, dyspnea, tachypnea, hemorrhoids, parotid enlargement and arterial hypotension.

Tests: Some diagnostic tests that your clinician might ask for include lab tests such as CBC, coagulation tests, BUN, creatinine, electrolyte levels and liver function tests to confirm the diagnosis.

In addition, your gastroenterologist might resort to ultrasonography, MRI or a CT scan. In some cases, your clinician might perform measure of the hepatic venous pressure gradient in order to assess the progress of the condition and to help ascertain treatment response. He will also resort to an upper EGD procedure to check for the presence of esophageal varices and to enable therapeutic intervention.

Example: Your gastroenterologist reviews a 64-year-old male patient for complaints of abdominal pain, vomiting and nausea that has been persistent for the past 15 days or so. The patient also complains of severe weight loss and anorexia that has been present for a couple of months now. The patient is HIV positive and has been on antiretroviral therapy for about four years. He has no history of alcohol intake or drugs. He says that he has had no abdominal complications until now.

Upon examination, your clinician notes signs of anemia, dyspnea, tachypnea and ascites. Your gastroenterologist asks for lab tests like CBC, coagulation time, LFT, BUN, creatinine, albumin, globulin and bilirubin levels. The LFT tests showed increased levels of AST (Aspartate transaminase); ALT (Alanine transaminase) and GGT (Gamma GlutamylTranspeptidase) while creatinine, albumin, globulin and bilirubin levels were all normal.

The patient’s abdominal CT scan showed the presence of ascites and portal vein thrombosis. There were no signs of any splenomegaly. Your gastroenterologist performed an upper EGD that revealed one Grade 2 and two Grade 1 esophageal varices but no signs of hemorrhage or bleeding from the varices.

Based on history, signs and symptoms, physical examination, and results of lab tests and diagnostic studies, your clinician arrives at a diagnosis of portal hypertension.

What to report:You should report the evaluation of the patient using 99223 (Initial hospital care, per day, for the evaluation and management of a patient…). You should report the EGD procedure done to control the bleeding with 43235 (Esophagogastroduodenoscopy, flexible, transoral; diagnostic, including collection of specimen[s] by brushing or washing, when performed [separate procedure]).

You should report the diagnosis with 572.3 if you’re using ICD-9 codes or report K76.6 if you’re using ICD-10 codes.

Because the E&M service was done on the same date, you should be on the look-out for a denial from the carrier.  Some carriers are rather strict and consider all E&M services performed on the date of any procedure as included in the procedure fee.

If you get a denial, then you should appeal and append modifier -57 (Decision for surgery) to the E/M service for the evaluation a patient who, as a result of that evaluation, requires a procedure that will be performed the same day. This is the decision-making E/M.The same modifier should be used on future claims to that carrier to avoid repeating the denial and appeal cycle.