Gastroenterology Coding Alert

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Enemas are a bit confusing for coders, and for good reason. For the most part, enema codes have little to nothing to do with the procedure as we think of it. In this article, we’ll discuss these commonly misused codes and how to properly use them, and fill you in on how to report the outpatient procedure commonly referred to as an “enema.”

Procedure refresh: An enema to relieve severe constipation is an outpatient procedure in which the provider injects liquid through the anal canal, which allows fluid to soak and loosen hardened waste matter in the patient’s colon.

Question: Aren’t All Enemas Reported with 74283 or 74270?

Answer: No, those are imaging codes. Let’s break it down by code:

74283: When the gastroenterologist describes a therapeutic enema in the office to relieve constipation, of course you’d consider reporting the encounter with 74283 (Therapeutic enema, contrast or air, for reduction of intussusception or other intraluminal obstruction (eg, meconium ileus)). This seems pretty straightforward, given the procedure shows up prominently in the code descriptor. However, if you look at where this code appears in the CPT^® code book, you’ll see 74283 is part of the Diagnostic Radiology (Diagnostic Imaging) Procedures of the Gastrointestinal Tract code set.

This means you report 74283 for imaging enhancement, such as a barium enema, which is an X-ray exam that can detect changes or abnormalities in the colon. Barium enemas are sometimes also used as an alternative to colonoscopies to screen for colon cancer. “Occasionally a barium enema technique is used to treat a blockage by neonatal stool in a newborn, or a rare kind of intestinal obstruction in an adult,” says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California.

74270: Similarly, coders can mistakenly turn to 74270 (Radiologic examination, colon, including scout abdominal radiograph(s) and delayed image(s), when performed; single-contrast (eg, barium) study) when they’re trying to code an enema for constipation relief. However, like 74283, this code describes a radiology exam for viewing the intestine.

When the provider describes using a suspension of barium sulfate to delineate the lining of the colon and rectum, this is likely the time to use 74270. During this procedure, the provider administers the barium sulfate, which is chalk-like and appears white on the X-ray, via the rectum. The barium is held inside the colon while

they take X-rays of the patient’s intestine. This is not the type of enema procedure we’re trying to code, however, when the documentation refers to an outpatient enema for constipation.

Question: For an Outpatient Enema, Do I Report a Procedure and an E/M?

Answer: As mentioned previously, enema administration may also be performed therapeutically to relieve intussusceptions or intestinal obstructions, such as constipation. When the gastroenterologist performs an enema in the office for the removal of impacted feces, that procedure is included in the evaluation and management (E/M) code for a particular date of service. There is no separate procedure code. Typically, that means you’ll select from 99202-99215 (Office or other outpatient visit for the evaluation and management …). Which code you select will depend on the specifics of the encounter as outlined in the physician’s documentation.

Append correct dx: To show medical necessity, the diagnosis code and any applicable history codes will need to appear with the claim. As for the ICD-10 code, you should report the appropriate constipation code, such as K59.00 (Constipation, unspecified), as the primary diagnosis for this scenario, followed by any additional diagnoses that may exist, such as K50.10 (Crohn’s disease of large intestine without complications).

Note: When it comes to the enema cost, you can ask the patient to purchase what’s needed and bring it to the office, if you arrange it ahead of time, says Glenn D. Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT^® Editorial Panel member in Pasadena, California. “Or, if the patient is informed ahead of time, the cost can be charged as a noncovered item separate from the visit,” he notes. “Gastroenterology offices ordinarily do not have the ability to bill durable medical equipment (DME) and supplies to payers.”