Gastroenterology Coding Alert
Determine Which Details to Consider for This Claim
Question: We have a patient suffering from gas build-up, flatulence and chronic constipation. The gastroenterologist suspects celiac disease but ordered an antibody test. The patient has type 1 diabetes as well as a history of irritable bowel syndrome (IBS). Which of these details should I report on the claim? Georgia Subscriber Answer: According to ICD-10-CM Official Guidelines, Section I.B.4, you’ll code the signs and symptoms “when a related definitive diagnosis has not been established (confirmed) by the provider.” You’ll also want to code applicable signs and symptoms to help support medical necessity for any antibody tests the doctor orders or any procedures they perform, such as an esophagogastroduodenoscopy (EGD). You should list all the symptoms you mentioned before the provider is ready to offer a definitive diagnosis: For reference, the following symptoms might also be relevant if a patient with suspected celiac disease presents for evaluation: History: In addition to symptoms that the physician records during the exam, the patient’s personal, family, and social history helps the gastroenterologist assess the likelihood of celiac disease. These details are a pertinent pieces of the patient’s medical record going forward, and while not required, they provide a complete picture and could influence future treatments. This means that you should absolutely code the diabetes and IBS: Other important pieces of personal or family history should be documented if relevant. Here are a few examples for reference:
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