Gastroenterology Coding Alert

Question: Our gastroenterologist recently evaluated a two-year-old male patient who was brought in by his mother with complaints of severe abdominal pain. The child's mother told the gastroenterologist that the child had this pain intermittently and it was so severe that the child would kick his legs in the air whenever the pain increased. She also said the child developed an upper respiratory tract infection around ten days ago and the symptoms of abdominal pain had been occurring from the night before. She added that the child appeared to be fatigued and complained that he had been throwing up every now and then. After performing an exam and testing, the gastroenterologist diagnosed the patient with intussusception. We've never coded this before, so can you advise which codes apply?

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Answer: You should report the evaluation of the patient with the appropriate E/M code, such as 99201-99215, and report the diagnosis with K56.1 (Intussusception). This diagnosis code applies whether the intussusception was found in the bowel, colon, intestine, or rectum, according to ICD-10 guidelines.