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Gastroenterology Coding Alert

Reader Question:

Infection Affects Pouchitis Diagnosis

Published on Fri May 07, 2004

Question: What is the proper diagnosis code for pouchitis, and is there a different code if the pouchitis is specified as an infectious process?

Louisiana Subscriber

Answer: 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.

For standard cases of pouchitis, use the ICD-9 code 558.9 (Other and unspecified noninfectious gastroenteritis and colitis). If the pouchitis is infectious, however, report 558.9 and 997.4 (Complications affecting specified body system, not elsewhere classified; digestive system complications).

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.

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