Gastroenterology Coding Alert

Question: A new Medicare patient reports to the gastroenterologist with complaints of diarrhea, stomach pain, and loss of appetite for the past week. The gastroenterologist performs a level-three E/M; suspecting Crohn's disease, she performs a colonoscopy with biopsy. Test results come back positive for Crohn's, but negative for cancer. How should I code this scenario?

Iowa Subscriber

Answer: You'll need to double check the notes to see if the physician specified the type of Crohn's disease. Further, it is unusual to have a new patient visit on the same day as a colonoscopy because the procedure requires the patient to complete a full colonoscopy preparation. If the notes indicate that the patient was fully prepared for the colonoscopy on the day of the initial visit, report the following codes:

• 45380 (Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple) for the colonoscopy

• 99203 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a detailed history; a detailed examination; medical decision making of low complexity ...) for the E/M

• modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to 99203 to show that the E/M and colonoscopy were separate services.

Dx coding: If the gastroenterologist confirms Crohn's disease, report one of the following:

• 555.0 -- Regional enteritis; small intestine

• 555.1 -- ... large intestine

• 555.2 -- ... small intestine with large intestine

• 555.9 -- ... unspecified site.

If the physician does not reach a definitive diagnosis, you'll need to code the symptoms: 787.91 (Other symptoms involving digestive system; diarrhea), 789.00 (Other symptoms involving abdomen and pelvis; abdominal pain; unspecified site), and 307.59 (Other and unspecified disorders of eating; other).