Gastroenterology Coding Alert
Double Check Documentation for Type of Pouchitis
Question: One of our patients has been diagnosed with pouchitis. Which ICD-9 code should I use? Are there any other points to consider?
New Jersey Subscriber
Answer: For standard cases of pouchitis, you should report ICD-9 code 569.71 (Inflammation of internal ileoanal pouch). The same code applies for infectious cases.
Pouchitis, which presents as inflammation of the mucosa of the small intestine. Pouchitis is the most common long-term complication of ileal pouch surgery, such as ileostomy or ileo-anal anastomosis procedures and has a significant adverse impact on patient quality of life. A common prescription, when a patient develops pouchitis, is antibiotics such as metronidazole (Flagyl).
Note: Confirm the diagnosis by looking at the GI documentation. Some of the symptoms of the condition include:
If your patient has any of these symptoms, be sure to include that in your documentation.
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