Gastroenterology Coding Alert
Let Provider Be Decider in This Ulcer Encounter
Question: One of our patients recently presented with an ulcer they’ve only experienced for the last two weeks. Can I assume the ulcer is acute? South Carolina Subscriber Answer: Whether a condition is acute or chronic is a distinction only the provider can make. Therefore, what you report will depend mostly on the documentation. If the doctor doesn’t specify that detail in the documentation, you may need to ask them for more information before choosing the best diagnosis code. Keep in mind though that when it comes to ulcers, providers can’t usually make that distinction right away. There are a few exceptions, however. For example, if a patient starts a non-steroidal anti-inflammatory drug (NSAID) and develops an ulcer a few weeks later, the gastroenterologist might be able to diagnose an acute ulcer. On the other hand, the patient may instead have chronic asymptomatic ulcer disease. If your provider is unable to specify yet whether the condition is acute or chronic, you’ll have to report an unspecified code, such as K25.9 (Gastric ulcer, unspecified as acute or chronic, without hemorrhage or perforation), assuming the other details in the descriptor are also accurate.
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