Code the Signs and Symptoms for Suspected Celiac Disease
Question: We are treating a patient who is experiencing persistent constipation, flatulence, and accumulation of gas. The gastroenterologist has raised the possibility of celiac disease and has requested an antibody test. The patient has type 1 diabetes as well as a history of irritable bowel syndrome (IBS). How should I accurately report this on a claim? AAPC Forum Participant Answer: Whenever there are signs and symptoms, but no definitive diagnosis from the practitioner, according to ICD-10-CM Official Guidelines, Section I.B.4, you should code the signs and symptoms on your claim. You’ll also want to code these to help support medical necessity for any antibody tests the doctor may order or any procedures they perform, such as a possible esophagogastroduodenoscopy (EGD) later on. You should list the following symptoms you mentioned: Beyond the symptoms noted by the physician during the examination, the patient’s personal, family, and social history help the practitioner in evaluating the potential for celiac disease. These details, although not mandatory, form crucial components of the patient’s ongoing medical record. They offer a comprehensive view and may impact subsequent treatment strategies. This means that you should absolutely code the diabetes and IBS using the following code categories: You should document other important pieces of personal or family history if they are relevant. Here are some examples for reference: Make note: The following symptoms may also be relevant if a patient with suspected celiac disease presents for evaluation: What’s the difference? Celiac disease and IBS are distinct digestive conditions with different causes and treatments. Celiac disease is an autoimmune disorder triggered by gluten, leading to small intestine damage and potential nutrient malabsorption. While IBS is a chronic disorder that affects the large intestine and causes symptoms like cramping, abdominal pain, bloating, gas, and irregular bowel movements, it doesn’t alter bowel tissue or increase colorectal cancer risk. Treatment for celiac disease involves a lifelong gluten-free diet, while IBS management includes dietary changes, stress management, and medication. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
