Gastroenterology Coding Alert

Crohn's presents a coding challenge

From diagnosis to treatment, reporting for Crohn's patients can be tricky. Follow these three steps to increase your reimbursement for Crohn's diagnosis, management and treatment.
 
Crohn's disease, also called ileitis or regional enteritis, is an inflammatory bowel disease (IBD) that typically irritates the small intestine but can also be found in any part of the digestive tract. Those with Crohn's disease have frequent pain from intestinal inflammation and often have diarrhea. There is no cure for Crohn's disease, but several treatments are available.
 
In many gastroenterology offices, not much time passes between visits from patients with Crohn's disease, according to Lois Curtis, CPC, of Gastroenterology Associates in Evansville, Ind.
 
"You go in spurts sometimes: You get a lot (of Crohn's patients), and then it tapers off a while," she says. "But we're always getting patients with Crohn's or diagnosing patients with it." 

Identify Initial Visits That Are Consultations

In many cases, a gastroenterologist's first encounter with a Crohn's patient is a "referral": The patient has some sort of gastroenterological problem, and her primary-care physician decides that a gastroenterologist's opinion is needed.
 
Even if a patient is found to have Crohn's disease and eventually comes under your office's care, the initial meeting with her is still a consultation.
 
If the patient reports initially because she (or her doctor) decided that a gastroenterologist's opinion was in order, choose the appropriate code from the outpatient consultation codes 99241-99245 (Office consultation for a new or established patient ...).

According to Delia Bartolotto-Stewart, CPC, of Digestive Health Physicians in Fort Myers, Fla., this is how most patients with Crohn's symptoms end up on her office's appointment books.
 
"A patient has a pain or diarrhea problem, the (primary-care) doctor isn't sure if it's Crohn's ... and our office determines that," she says.
 
If the gastroenterologist is to provide a second or third opinion about a patient with Crohn's symptoms, you should assign one of the confirmatory consult codes 99271-99275 (Confirmatory consultation for a new or established patient).

Code the Chosen Method of Diagnosis

Gastroenterologists have several options when testing for Crohn's disease. They can order simple blood tests to measure for an abnormally high number of white blood cells or a high sedimentation rate, a sign of inflammation somewhere in the body. They can also order fecal-occult blood tests to detect intestinal bleeding, a problem common to Crohn's.
 
Due to its sensitivity to lower-bowel bleeding, physicians most often use the guaiac-based test in fecal-occult tests; the proper CPT code for this test is 82270 (Blood, occult, by peroxidase activity [e.g., guaiac] qualitative; feces, 1-3 simultaneous determinations).
 
Perhaps the most common way to test for Crohn's is with colonoscopy, during which the physician can check for inflammation or bleeding and take tissue for biopsy. The gastroenterologist will often examine the terminal ileum; this procedure is included in the standard colonoscopy codes. You should not report an additional small-bowel enteroscopy with the colonoscopy code. Choose the appropriate code from the colonoscopy group (45378-45387) when your physician uses this diagnosis method.
 
Curtis asserts that her doctors opt for colonoscopies most of the time, due to the thoroughness of the procedure.
 
"It really depends on what kind of symptoms with which the patient presents, but ideally, if they [doctors] suspect a patient has Crohn's, the test of choice would be colonoscopy," Curtis says. "They can actually see what's taking place in the colon and find any irregularities causing the symptoms."
 
Colonoscopies are a common tool for diagnosis because biopsy is possible and the mucosa of the intestines (visible during a colonoscopy) can be a sign of Crohn's in a patient.
 
"If the test has the look of the mucosa of a Crohn's patient, then a doctor can pretty much spot it [Crohn's] at that point in time," Curtis says.

Choose a Treatment Option

Once a gastroenterologist diagnoses Crohn's disease, he chooses among several options for treatment. Changes in diet and lifestyle are always the first steps, along with medication containing the anti-inflammatory agent mesalamine, such as sulfasalazine, Asacol, Dipentum or Pentasa. Another medication option features drugs that suppress the immune system - such as 6-mercaptopurine and azathioprine - along with corticosteroids to control inflammation.
 
Partial colectomies and small-bowel resections are occasionally necessary surgeries for Crohn's patients, but often the inflammation returns to the very area the intestine has been removed from. In some instances, the condition is so serious that a total colectomy becomes necessary. If a patient undergoes a partial or total colectomy, report the procedure using the appropriate code from 44140-44160 (Colectomy ...). Crohn's patients may also require surgery to address symptoms not responding to medical therapy or to correct blockages, perforations, abscesses or intestinal bleeding.
 
Physicians often treat moderate to severe cases of Crohn's disease with an intravenous infusion regimen using the drug infliximab, more commonly known as Remicade. This is a relatively new - and costly - option, so offices must often prove that conventional treatment options failed before using Remicade.
 
"It's a good treatment, but due to the fact that it's so costly, our doctors try to work with patients to see what treatment is most effective for them," Curtis says.
 
Physicians administer Remicade intravenously in a procedure that often takes at least two hours. This leads some gastroenterologists to perform the infusion at a hospital, but it can also be done in an office or outpatient setting. The infusion code 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour), along with add-on code +90781 (... each additional hour, up to eight hours ...), is used to report Remicade infusion sessions. (For a more comprehensive look at reporting Remicade injections, see "Want Remicade Reimbursement? Prove Medical Necessity, Watch the Clock" in this issue.)