Gastroenterology Coding Alert

Question:What is the proper diagnosis code for pouchitis, and is there a different code if the provider specifies that the pouchitis is an infectious process?

Louisiana Subscriber

Answer: 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.
 
For standard cases of pouchitis, use ICD-9 code 558.9 (Other and unspecified noninfectious gastroenteritis and colitis). If the pouchitis is infectious, however, report 558.9 and 997.4 (Complications affecting specified body system, not elsewhere classified; digestive system complications).

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.