Primary Care Coding Alert

Also: find several GI symptom codes for quick reference.

Gastrointestinal problems can present a seemingly infinite number of symptoms and diagnoses, which can make coding these types of encounters challenging. Primary care practitioners (PCPs) see a lot of bellyaches that don’t require a referral to a specialist, which means coders need to have a solid understanding of the applicable codes.

Here you’ll find a few clinical examples of common GI ailments and how to code them.

Apply Correct Codes for Abdominal Pain

Abdominal pain can be a fairly ambiguous symptom, but it’s one of the most commonly reported. However, it’s also common to find that the medical record does not have the most detailed set of notes that outline the specifics of the situation. This won’t always require a query, however.

Example: Let’s say a 31-year-old patient came in complaining of abdominal pain that’s persisted for the last 24 hours. The pain is accompanied by flatulence, but no vomiting or diarrhea. The patient’s last bowel movement was that morning, but it was hard to pass. The provider examined the patient and found generalized tenderness to deep palpation in abdomen, but no localized tenderness or masses during the rectal exam. Which ICD-10 codes should you report?

Coding: Even though there aren’t many specifics, there are still a couple of applicable codes you can use. You can code R10.84 (Generalized abdominal pain) to account for the generalized pain. For the tenderness, you can report R10.817 (Generalized abdominal tenderness).

Documentation alert: Abdominal pain refers to any pain between the chest and groin, and there are a lot of different organs in there. Therefore, the more specific the provider can get about location and severity of pain, the more ithelp their own clinical decision making andhelp you code to the highest specificity.

For example, pain concentrated in a particular area that starts suddenly and unexpectedly could indicate a problematic appendix or gallbladder. A pain that manifests as a generalized pain in the belly is usually due to a stomach virus, indigestion, or gas. In other cases, kidney stones and gallstones could give rise to colic pain.

If you see frequent mentions of “abdominal pain” with no further detail, communicate with your providers to help them understand the extent to the R10 code set so that they can better see the value in documenting more exact symptoms.

Get it Right When Coding for GERD

Heartburn is another common problem primary care practitioners treat. When heartburn becomes chronic, however, the physician needs to look a little further.

Example: An established patient sees your PCP because of persistent heartburn. The provider performed a thorough examination, then assigned a confirmed diagnosis of gastrointestinal reflex disease (GERD) and started the patient on GERD medication to relieve the symptoms. Is this a situation that calls for the diagnosis code in addition to the signs and symptoms?

Coding: If your provider identifies GERD in the absence of esophagitis, you will need to assign K21.9 (Gastro-esophageal reflux disease without esophagitis). You may want to be sure about whether the patient has esophagitis or not, before assigning this code. Don’t worry about sending a query to your provider yet. You can code K21.9 as a default code for GERD as it includes esophageal reflux NOS. If the GERD includes esophagitis, you will need to assign K21.0- (Gastro-esophageal reflux disease with esophagitis).

Signs and symptoms: As for coding signs and symptoms, only report these when there is no definitive diagnosis. If the patient has heartburn and indigestion but GERD has not been specifically diagnosed, then the signs and symptoms would be coded. For example:

• R12 (Heartburn)
• R05.- (Cough)
• R10.13 (Epigastric pain) (includes dyspepsia NOS)R06.2 (Wheezing)
• R07.9 (Chest pain, unspecified)

Important: The symptoms listed above can sometimes also be caused by cardiac or pulmonary problems, so make it a point to report any pre-existing chronic conditions and habits that may exacerbate GERD, such as asthma (J45.-), obesity (E66.-), smoking, pregnancy, and hereditary predisposition.

See Your Way Through This Gastroenteritis Case

Often, the clinician requires multiple visits before making a definitive diagnosis. Something like gastroenteritis can have many causes, so you have to be careful to report the codes that correctly correspond with each of the patient visits and not to jump the gun on reporting any suspected diagnoses.

Example: Your PCP sees a mother with her child. The 4-year-old has been experiencing diarrhea, vomiting, and abdominal pain for two days, accompanied by a low-grade fever. The PCP noticed the child was lethargic and appeared dehydrated. The provider diagnosed gastroenteritis and ordered a stool test to determine the origin. The patient and mother came in for a follow-up two days later. The fever and stomach pain were the only symptoms reported, and the test results said norovirus was the origin.

Coding: For the first visit, you’ll report K52.9 (Noninfective gastroenteritis and colitis, unspecified) because the origin was not known.

Based on what’s written in this case, you will also report the following symptoms codes:

• R11.2 (Nausea with vomiting, unspecified)
• R50.9 (Fever, unspecified)
• E86.0 (Dehydration)

Remember: You likely remember from the first clinical scenario that R10.- codes describe abdominal pain, but you won’t report abdominal pain for this case. You’ll only select a code from R10.- if “a related definitive diagnosis has not been established (confirmed) by the provider,” per ICD-10 coding guideline I.C.18.a. Because the PCP made a diagnosis that implies stomach pain, you’ll only use an R10 code if the stomach pain is not “associated routinely with a disease process,” as guideline I.C.18.b goes on to tell you.

Medical necessity: The PCP ordered a stool test to further assess the origin of the gastroenteritis. Reporting the abovementioned symptoms will help support the medical need for this test.

For the second encounter, the PCP determined that Norovirus is the cause of the gastrointestinal condition, which codes to A08.11 (Acute gastroenteropathy due to Norwalk agent). The child still has a fever and abdominal pain, but because abdominal pain is assumed with the illness, you’ll code R50.9 with the diagnosis to account for the fever.