Radiology Coding Alert

Question: A 38-year-old patient visits our imaging facility after visiting their primary care physician (PCP). The patient is complaining of acute lower abdominal pain. The patient’s symptoms include diarrhea, pain that worsens as they move, and exacerbated pain after eating. Their PCP initially suspected diverticulitis but wants further examination. After a CT scan with contrast, the radiologist diagnoses the patient with epiploic appendagitis. 

What codes do I need to report this encounter?

Idaho Subscriber

Answer: For your scenario, you’ll assign K65.9 (Peritonitis, unspecified) for the epiploic appendagitis diagnosis. Epiploic appendagitis occurs when the small pouches of fat situated over the large intestine, or colon, lose blood flow and become inflamed. The pouches, called epiploic appendages, can cause intense abdominal pain when inflamed. Plus, the rare condition is commonly confused with appendicitis or diverticulitis.

While there isn’t a specific code for epiploic appendagitis, the condition occurs near the peritoneum. The descriptor for K65.9 indicates the inflammation of the peritoneum, which is the best match for the patient’s diagnosis. Additionally, parent code K65.- (Peritonitis) features a note to use an additional code from B95-B97 to document any known infectious agent.

You also indicated the radiologist performed a computed tomography (CT) scan with contrast media to diagnose the patient. For the procedure, you’ll assign CPT^® code 74160 (Computed tomography, abdomen; with contrast material(s)).