Three Gastro Cases Show ICD-10’s Coding Significance

Changes in coding guidelines will make documentation far more critical.

By Essie White, CPC, CPC-H, CPC-I, CGSC, CPMA

Those of us who have been around for decades have seen many changes in the medical profession. I remember working with the first CPT® book. Since then, the Centers for Medicare & Medicaid Services (CMS) has mandated ICD-9-CM codes for claim forms, HCPCS Level II codes came into effect, electronic health records (EHRs) have become a reality, and changes to codes and coding regulations occur nearly every week. I tell my students, if you can’t handle change, or if you expect everything to be black and white, you chose the wrong profession.

Effective Oct. 1, 2013, we face yet another, massive change: the implementation of ICD-10-CM and ICD-10-PCS. Outpatient coders must learn a completely new diagnosis coding system. Inpatient coders will have to learn both the diagnosis codes and the procedures system.



To illustrate the coding significance of the transition from ICD-9 to ICD-10, consider the following examples taken from gastroenterology, a favorite specialty of mine.

Case 1: A 50-year-old patient without complaints or symptoms comes in for a screening colonoscopy. The physician performs the procedure with normal findings and tells the patient to return in five years for a repeat screening.

To code this scenario using ICD-9-CM, begin your search in Volume 2 Index. Look up “screening,” scan alphabetically to “colon,” and find V76.51. After finding the code in the index, always refer to the code in the Volume 1 Tabular List. Here you can see that V76.51 Special screening for malignant neoplasms; colon is indeed for a screening colonoscopy. If you are looking for rectum or small intestine, however, you can see that this is not the correct code.

Now, let’s code the same scenario using ICD-10-CM. Some of the same rules apply: Begin your search by looking in Volume 2 Index. Start with “screening” and then scan down to “colon” to find Z12.11. Then go to the Volume 1 Tabular List to find Z12.11 Encounter for screening for malignant neoplasm of colon. You will find there is a parenthetical note that defines “screening,” and also a “use additional” note reminding you to also code if there is a family history of malignant neoplasm from the Z80-section of codes.

Case 2: A 60-year-old patient without complaints or symptoms comes in for a screening colonoscopy. The physician performs the procedure and snares a tubular adenoma in the cecum.

Looking first at ICD-9-CM, the primary diagnosis is the screening, V76.51. Next, look in the index under “Adenoma” and then scan down to “Tubular.” You are instructed to “see also Neoplasm by site, benign.” In the ICD-9-CM Neoplasm Table, you will find “colon,” which instructs you to “see also Neoplasm, intestine, large.” Look to “intestine, large, cecum” in the benign column to locate 211.3. Verify this code in the Tabular List as Benign neoplasm of other parts of digestive system; Colon.

Switching to ICD-10-CM, the primary diagnosis is Z12.11. Find “adenoma” by looking in Volume 2 under “adenoma, tubular.” You are instructed to “see also Neoplasm, benign, by site.” ICD-10-CM does not include an alphabetical Neoplasm Table like the one in ICD-9-CM. The table instead is found at the end of the alphabetic list, before the Table of Drugs and Chemicals. In this table, look under “colon” to find the codes for primary and secondary malignancies only. Search under “intestine, large” to find “cecum.” In the “benign” column, find D12.0, which must be verified in the Tabular List. D12.0 Benign neoplasm of the cecum has an “excludes” note to remind you that if you are looking for benign carcinoid tumor of the large intestine and rectum, to see instead D3a.02-.

Case 3: A 55-year-old patient with a family history of colon cancer arrives complaining of abdominal pain and rectal bleeding. The physician passes the colonoscope and encounters a mass at the hepatic flexure. He takes a biopsy and the pathology is reported as malignant. He stops the scope procedure and (with prior consent) performs a partial colectomy with colostomy.

The primary diagnosis is cancer of the hepatic flexure. To code this diagnosis from ICD-9-CM, reference the Neoplasm Table. Look to “intestine, large, colon, hepatic flexure, malignant,” to find 153.0 Malignant neoplasm of colon; Hepatic flexure. Family history of colon cancer is coded to V16.0 Family history of malignant neoplasm; Gastrointestinal tract. There is no need to code the incidental symptoms of abdominal pain or rectal bleeding.

Using ICD-10-CM, scan the Neoplasm Table to find “colon” and code C18.9 Malignant neoplasm of colon, unspecified. The physician stated neoplasm of the hepatic flexure; therefore C18.9 Unspecified is inappropriate. Glance at the C18- code range and locate C18.3 Malignant neoplasm of hepatic flexure. The family history of colon cancer is coded to Z80.0.

Get Started with ICD-10

By now you should be preparing your providers, staff, data entry, billing departments, and information technology (IT) staff for the change to ICD-10. Although it may be too early to begin learning ICD-10-CM codes, now is a good time to learn about the administrative changes that will be necessary to accommodate it.

For example, how will you train your providers to be more specific? Sometimes all that is required is an additional word or two. In Case No. 3, the physician was specific in the type and location of the malignancy. If he had documented a colon polyp, you would have found K63.5. An inflammatory polyp would be coded as K51.4-, which needs further clarification of bleeding, obstruction, fistula, abscess, or other complications.

As a coder, it is up to you to educate yourself and be ready for the changes ICD-10 will bring. For instance, you could choose five charts per week, per provider, and code using both ICD-9-CM and ICD-10-CM. Use the knowledge you gain to conduct training sessions with the staff and introduce everyone to the required changes.

As an instructor, I see the need for better understanding terminology and physiology. As such, another good starting point would be to take a class or study online through AAPC. During your local chapter meetings, review the anatomy and terminology for a different body system each month.

Most importantly, don’t sit back and expect the information to be handed to you. Get involved in the process and uphold the ethics and standards you swore to when you became a member of AAPC. Lastly, be ready to take the proficiency exam by October 2013 to keep your well-earned credentials.


ICD-10 Demands More Precise Documentation

With the adoption of ICD-10, changes in coding guidelines will make documentation far more critical. Related to gastroenterology, for instance, Crohn’s disease, ulcerative colitis, and polyps all have criteria that must be indicated as “with or without” complication in the documentation. If there are complications, such as an abscess, bleeding, obstruction, fistulas, or other specified or unspecified complications, they have to be stated, as well. Diverticulitis and diverticulosis need to be documented as “with or without” perforation or abscess, and “with or without” bleeding. Irritable bowel syndrome (IBS) will need to be indicated as “with or without” diarrhea. Parasitic disease may be reported using a code from chapter 1, chapter 11, or using both chapters, depending on the causative agent or associated organism.

Many coding conventions will remain the same in the transition from ICD-9 to ICD-10, but there are exceptions. We will no longer indicate that an additional digit is necessary by using an “x” as a placeholder. Instead, an additional character is shown as necessary by using a dash “–.” ICD-10-CM uses both the number zero (0) and the letter “O.” The beginning character will be a letter followed by either letters or numbers (letters will not be case sensitive).

Essie White, CPC, CPC-H, CPC-I, CGSC, CPMA, is senior coding consultant for Healthcare Coding Consultants of Hawaii, LLC. Her responsibilities include coding, auditing, and training. Formerly, she was a bill reviewer of worker’s compensation and auto insurance claims, and has 18 years of administration and clinical experience in general and plastic surgery. She is also a part-time coding instructor at the University of Hawaii Kapi’olani Community College and an AAPC ICD-10 implementation instructor.


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