Differentiate Intestinal Diverticula, Diverticulosis, and Diverticulitis
When accurate diagnosis coding pressure builds, look at location and hemorrhaging for each.
By Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC, CCS, CCS-P
Diverticula are small “pouches” that poke through the muscle wall of the intestines, generally due to pressure within the intestine. They occur most frequently in the sigmoid colon (where internal pressure is highest), and are common in older patients (at least half of individuals over age 60 have diverticula, according to estimates).
The condition of having intestinal diverticula is called diverticulosis. Appropriate diagnosis coding for diverticulosis depends on the precise location of the diverticula and whether there is mention of hemorrhage (bleeding).
|Diverticulosis||w/o mention of hemorrhage||w/ mention of hemorrhage|
Diverticulitis Is Diverticulosis, with a Difference
Diverticulitis occurs when the intestinal diverticula become inflamed and/or infected. Diagnosis coding is similar to that for diverticulosis, based on location and whether hemorrhage is documented:
|Diverticulitis||w/o mention of hemorrhage||w/ mention of hemorrhage|
Note: A similar condition, called duodenitis (535.6x; a fifth digit is required to specify either with or without obstruction), may occur in the duodenum. Although this article covers only intestinal diverticula, diverticula may develop in any hollow organ, such as the esophagus, stomach, bile ducts, ureters, bladder, etc.
Diverticulitis may lead to complications, such as intestinal abscess (e.g., 569.5 Abscess of intestine) and fistula (e.g., 569.81 Fistula of intestine, excluding rectum and anus). In addition, 569.82 Ulceration of intestine may be associated with diverticula, as may 569.83 Perforation of intestine.
Diverticulosis and mild diverticulitis often are treated conservatively with recommended changes in diet, the use of over-the-counter pain medications, and possibly bed rest. Physician counseling and management are part of any evaluation and management (E/M) services provided.
More severe cases of diverticulitis with acute pain and complications may require a hospital stay, and may be treated with intravenous antibiotics and/or several days without food or drink to allow the colon to rest. Once again, physician management is part of any inpatient E/M services billed.
In extreme cases, surgery may be required. For example, emergency surgery may be necessary if peritonitis (567.xx) is present. The most common surgical treatment for emergency left-side complicated diverticulitis is the Hartmann type procedure (open, 44143 Colostomy, partial; with end colostomy and closure of distal segment (Hartmann type procedure), or laparoscopic, 44206 Laparoscopy, surgical; colectomy, partial, with end colostomy and closure of distal segment (Hartmann type procedure)). The diseased segment of the bowel is removed and an end colostomy is formed (the end colostomy may be reversed when the patient has made a recovery). Primary anastomosis is not performed due to the risk of infection.
If the risk of infection is minimal but surgical treatment is required, the surgeon may perform colonic resection with primary anastomosis (open, 44140 Colectomy, partial; with anastomosis, or laparoscopic, 44204 Laparoscopy, surgical; colectomy, partial, with anastomosis). In this case, the diseased portion of the bowel is removed, and the two resulting ends are reconnected (anastomosis).
Until Sure, Stick with Signs and Symptoms
Physicians cannot report “rule out” diagnoses. That means unless a definitive diagnosis of diverticulosis/diverticulitis has been established, you must report signs and symptoms only.
Diverticulosis often is asymptomatic, and may be discovered incidentally as a result of an exam for other conditions. For example, diverticulosis often is diagnosed during a colonoscopy (e.g., for cancer screening). Symptoms, when apparent, include lower abdominal pain, bloating, blood in stools, and constipation.
Diverticulitis is a more serious condition, the most common symptom of which is abdominal pain (which may be severe and sudden, or worsening over time), cramping, nausea, vomiting, fever, chills, and changing bowel habits.
Why “Roughing It” Is Good for You
The underlying cause of diverticulosis is believed to be a low-fiber diet. Fiber is the part (sometimes called “roughage”) of fruits, vegetables, nuts, and grains that the body cannot digest. Fiber may be either soluble (which takes on a jelly-like consistency as it moves through the intestinal tract) or insoluble (which passes through the body almost unchanged). Both types of fiber absorb liquid and add bulk to stool, which helps to prevent constipation and straining.
For most individuals, a high-fiber diet is superior to a low-fiber diet. A high-fiber diet is good not only for the intestines, but also is heart-healthy (soluble fiber is linked to lower cholesterol levels) and may help to control body weight. The American Dietetic Association recommends consuming 20 to 35 grams of fiber each day. Individuals with bowel disorders, such as Crohn’s disease or severe diverticula, may require a low-fiber diet, however.
Lack of exercise also may be associated with increased risk for diverticulosis, whereas the benefits of regular exercise are well documented.
So, trade your cookie for a carrot, and take a walk while you’re at it. Your colon will thank you!
Marcella Bucknam, CPC, CPC-H, CPC-P, CPC-I, CCC, COBGC, CCS-P, CCS, is the manager of compliance education for a large university practice group. She is the long-time consulting editor for General Surgery Coding Alert, and has presented at five AAPC national conferences.