Celiac Disease: Then and Now
Physicians know a lot more about the disease than they used to, but diagnosis remains difficult.
By Renee Dustman
Stomach pain, diarrhea, nausea, heartburn … these are common symptoms for any number of ailments. Twenty years ago, a physician’s first course of intervention for a patient complaining of gastric distress might’ve been simply to treat the symptoms with antacids, antiemitics, simethicone, and so on. If the patient returned with consistent or worsening symptoms, the physician might’ve ordered a diagnostic test, such as endoscopy.
Initial visit coding would’ve included an appropriate evaluation and management (E/M) CPT® code and one or more of the following diagnosis codes:
789.0 Abdominal pain
787.02 Nausea alone
Follow-up visit coding would include an appropriate E/M CPT® code and an endoscopy code, such as 43191 Esophagoscopy, rigid, transoral; diagnostic, including collection of specimen(s) by brushing or washing when performed (separate procedure) or 43200 Esophagoscopy, flexible, transoral; diagnostic, including collection of specimen(s) by brushing or washing, when performed (separate procedure), which includes moderate sedation.
Based on the negative results of the diagnostic testing (nothing would show up because the inflammation is in the intestine), the physician would likely diagnose the patient with dyspepsia and recommend he or she continue on antacids. Case closed.
536.8 Dyspepsia and other specified disorders of function of stomach
Twenty years ago, hardly anyone had heard of celiac disease (also called celiac sprue and gluten-sensitive enteropathy). Today, it’s practically a household word — along with the term “gluten free.” The disease is so prevalent, food manufacturers now label their applicable products “Gluten Free,” and a completely new category of gluten-free food products has entered the market. Even people who can eat gluten are going gluten-free, in an uneducated attempt to lose weight. Celiac disease isn’t a fad, however.
Diagnose the Disease
We now know celiac disease is an autoimmune disease characterized by an abnormal proximal small intestinal mucosa. It is associated with a permanent intolerance to gluten, and can present itself at any time in a person’s life. Symptoms may include those already mentioned, in addition to: bloating, weight loss, anxiety, anemia, skin rash, and dizziness.
Possible ICD-9-CM codes to support initial testing include:
250.0 – 250.9 Diabetes mellitus [with fifth digit 1 or 3]
564.00 – 564.9 Constipation
783.21 Loss of weight
783.9 Other symptoms concerning nutrition, metabolism, and development
787.3 Flatulence, eructation, and gas pain
789.00 – 789.09 Other symptoms involving abdomen and pelvis
V18.5 Family history of digestive disorders
Even with what we now know about the disease, diagnosis remains difficult because it’s often clouded by other conditions a patient with celiac disease may experience, such as dental and bone disorders, depression, irritability, joint pain, mouth sores, muscle cramps, and even neuropathy — any of which can manifest from intestinal malabsorption of nutrients due to celiac disease.
A definitive diagnosis, reported with ICD-9-CM 579.0 Celiac disease, can be obtained only by intestinal biopsy prior to removing gluten from the patient’s diet. Patients often forgo the invasive biopsy and rely on serologic tests to confirm the diagnosis; however, these blood tests only indicate the presence of antibodies known to be prevalent in individuals with celiac disease. This method usually involves follow-up blood tests to monitor the patient’s response to a gluten-free diet.
Treatment without a Cure
Treatment for celiac disease is both simple and difficult. It’s simple because all patients have to do is abstain from all gluten to start feeling better. It’s difficult because gluten exists in practically every processed food.
Specifically, gluten is a protein found naturally in the grain of wheat, rye, oats, and barley. Gluten comes in many forms and is identified by any number of names. Patients diagnosed with celiac disease require dietetic counseling to learn how to read labels and identify ingredients they cannot consume.
Coding for celiac disease is much easier now that the medical community recognizes it as a legitimate illness.
You’ll need to check payer policies but, generally, you’ll find insurers deem the following tests medically necessary in patients with signs or symptoms suggestive of celiac disease:
- Serologic measurement of tissue transglutaminase or antiendomysial antibodies
- Serologic measurement of anti-gliadin antibodies in children under 24 months of age
- Serologic testing to screen persons with type 1 diabetes mellitus
HLA-DQ2 and HLA-DQ8 testing to rule out celiac disease in patients with discordant serologic and histologic findings or if persistent symptoms warrant testing despite negative serology and histology
There are a few serologic tests many payers consider investigational in patients with signs or symptoms suggestive of celiac disease, however. Always check payer policies. There are no specific CPT® codes describing the serologic diagnosis of celiac disease, yet. We live in hope.
Renee Dustman is executive editor at AAPC.