Gastroenterology Coding Alert

Question: What diagnosis code should I use for pouchitis? Does the ICD-9 code change if the pouchitis is infectious? What are the ICD-10 equivalents?

West Virginia Subscriber

Answer: For standard cases of pouchitis, use 569.71 (Pouchitis), also known as inflammation of internal ileoanal pouch. But, if the pouchitis is infectious, you report 569.71 and 997.4 (Digestive system complications not elsewhere classified). Pouchitis, which is characterized by inflammation of the mucosa of the small intestine, can occur in the internal intestinal pouch reservoir after ileostomy or ileo-anal anastomosis procedures.

From October onward, for noninfective pouchitis, you will report the ICD-10 diagnosis codes K91.850 (Pouchitis). For reporting further complication of an infection, you will have to report K91.850 along with a code from among K91.3 (Postprocedural intestinal obstruction), K91.81 (Other intraoperative complications of digestive system), K91.89 (Other postprocedural complications and disorders of digestive system).

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.