ICD 10 Coding Alert

Hint: You may need to rely on signs and symptoms instead of a distinct Dx.

One of the foundational aspects of ICD-10-CM coding is looking to the documentation for a specific diagnosis. But sometimes, when coding gastrointestinal (GI) conditions, you may be unable to find a black-and-white ICD-10-CM code for a claim.

Try this quiz to evaluate your GI diagnosis code selection process.

Be Familiar With Normal Dx Results

Question 1: The gastroenterologist refers a patient to a radiologist for an abdominal computed tomography (CT) scan with a symptom of abdominal pain. The CT scan, when interpreted by the GI physician, reveals the presence of an abscess. Both the radiologist — when reporting for the technical component of the CT scan, and the gastroenterologist — when reporting for the follow-up E/M visit for the same test, should report a diagnosis of “intra-abdominal abscess” (K65.1 [Peritoneal abscess]). However, what should you do if the diagnostics had come out normal?

Answer 1: If the diagnostic test does not provide a definitive diagnosis or if it came out with normal results, you should code the sign or symptom that prompted the treating physician to order the study. Say, in the previous scenario, the CT scan results came back without any abnormal findings, then you would report the symptom (the abdominal pain) instead of K65.1.

If the diagnostic test was normal, but the referring physician records a suspected (a.k.a. probable, questionable, rule out, or working) diagnosis, you should not code the referring diagnosis. Instead, you should again report the presenting signs and symptoms. The ICD-10-CM guidelines warn, “The testing of a person to rule out or confirm a suspected diagnosis because the patient has some sign or symptom is a diagnostic examination, not a screening. In these cases, the sign or symptom is used to explain the reason for the test.” For instance, suppose the physician’s notes indicated “suspected blockage of a bile duct by gallstones,” but the CT scan came out normal. Again, you would report the symptom (R10.9) rather than the suspected condition as the reason for the test.

Keep in mind: If the patient is receiving only diagnostic services during the outpatient visit, you would list first the condition that is the main reason for the visit on the claim. This code should be your primary diagnosis. Then, code for other diagnoses (such as chronic conditions) on the following lines. For example, say a patient with chronic gastritis got the CT scan, and test results revealed the presence of a peritoneal abscess. On your claim you should list K65.1 as your primary diagnosis and K29.40 (Chronic atrophic gastritis without bleeding) as your secondary diagnosis.

Remember: “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification,” state the 2022 ICD-10-CM Official Guidelines for Coding and Reporting, which went into effect on Oct. 1, 2021. “Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present,” the guidelines note.

2. Code Duodenal Ulcers Like This

Question 2: A patient presents with burning, sharp pain in their upper abdominal area, and the gastroenterologist diagnoses them, by endoscopy, with a duodenal ulcer. How do you know which code to use?

Answer 2: To select the right duodenal ulcer code, you’ll need to know whether the issue was chronic or acute, and whether an obstruction, hemorrhage, or perforation was present.

When you see the K26 (Duodenal ulcer) category, you’ll notice that a fourth character is required. To pinpoint the most accurate fourth character, you’ll need some detail from the gastroenterologist’s report. If the condition is acute, you’ll look to the K26.0-K26.3 codes (Acute duodenal ulcer…), which are broken down further based on whether the acute duodenal ulcer had hemorrhage, perforation, both, or neither.

If you find that the patient suffers from chronic duodenal ulcers or you don’t have any indication of whether the condition was acute or chronic, you’ll instead need to look at the K26.4-K26.7 (Chronic or unspecified duodenal ulcer…) series. These codes also expand further depending on the presence of hemorrhage, perforation, neither, or both.

Finally, your only remaining option is K26.9 (Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation). This code is less specific and you’ll only report it if the gastroenterologist’s record lacks information about whether the ulcer was acute or chronic in nature. In cases of sparse documentation when the physician is unable to add more details, you should turn to this code.

3. Look to Cause of Pain When Possible

Question 3: A 25-year-old man presents with abdominal pain. The physician notes complaints of generalized abdominal pain for one day, with flatus, no vomiting or diarrhea. Last bowel movement (BM), the same morning, was of hard consistency. Abdomen examination reveals decreased bowel sounds, generalized tenderness to deep palpation in abdomen. The provider finds there is no localized abdominal tenderness or any palpable masses during the rectal exam. Which code applies?

Answer 3: Here you may have two options to choose from. You may code R10.84 (Generalized abdominal pain) to denote generalized abdominal pain; and to depict generalized abdominal tenderness, you may report R10.817 (Generalized abdominal tenderness).

Don’t forget: Abdominal pain is probably the most common complaint a gastroenterologist sees; it refers to any pain in the region between the chest and groin. The location, severity, and extent of the pain are crucial aspects for a provider’s clinical decision making, as well as deciding on an appropriate code. ICD-10 coding is very specific, noting that abdominal pain is found under chapter 18 of ICD-10, in category R10 (Abdominal and pelvic pain…). ICD-10 coding depends on the site, etiology, and manifestation or state of the disease or condition.