Gastroenterology Coding Alert

Question: What diagnosis code should I use for pouchitis? And does the ICD-9 code change if the pouchitis is infectious?

Georgia Subscriber

Answer: For standard cases of pouchitis, use 558.9 (Other and unspecified noninfectious gastroenteritis and colitis). But if the pouchitis is infectious, report 558.9 and 997.4 (Complications affecting specified body systems, not elsewhere classified; digestive system complications).

What it is: Pouchitis, which is characterized by inflammation of the mucosa of the small intestine, can occur after ileostomy or ileo-anal anastomosis procedures. Gastroenterologists typically prescribe antibiotics like metronidazole (Flagyl) when a patient develops pouchitis.

- Tip: Fortify your claim with documentation that substantiates pouchitis. Some of the symptoms of the condition include:

• abnormal number of stools in one day

• rectal bleeding

• urgency before bowel movements

• fever

• abdominal cramping.

If your patient has any of these symptoms, be sure to note it on your claim.