Gastroenterology Coding Alert

Question: Our gastroenterologist examined a patient and ordered an x-ray of the abdominal area, after which he diagnosed her with paralytic ileus. Which diagnosis code should we report?

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Answer: When your gastroenterologist diagnoses paralytic ileus, you’ll report K56.0 (Paralytic ileus). You’ll use the same code if your gastroenterologist reports the diagnosis as paralysis of bowel, paralysis of colon or paralysis of the intestine.

You cannot use K56.0 if the diagnosis is gallstone ileus (K56.3), ileus NOS (K56.7) or obstructive ileus NOS (K56.69).

Documentation spotlight: When your gastroenterologist arrives at a diagnosis of paralytic ileus, some of the signs and symptoms that you are most likely to see in the documentation of the patient will include abdominal pain, bloating, reduced appetite, vomiting and nausea. Your gastroenterologist might note signs of disturbances to passing of stools and flatus.

Upon examination, your gastroenterologist might note distension of the abdomen and in many cases might note tenderness of the distended area. One of the most important physical findings that might point your gastroenterologist to diagnose paralytic ileus upon physical examination might include the absence of bowel sounds.

Although there are many causes for paralytic ileus to occur, one of the most significant causes that you will see is that the patient will have undergone a recent abdominal or an intestinal surgery and the paralytic ileus could be an adverse complication that occurs following the surgery.

If your gastroenterologist suspects paralytic ileus, he may draw blood samples to check for infections, electrolyte and other metabolic imbalances. He might also order an x-ray to confirm the diagnosis of paralytic ileus and to check for the presence of obstruction.