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Gastroenterology Coding Alert

Reader Question:

Infection Affects Pouchitis Diagnosis

Published on Fri May 07, 2004

Question: What is the proper diagnosis code for pouchitis, and is there a different code if the pouchitis is specified as an infectious process?

Louisiana Subscriber Answer: Pouchitis, which is characterized by inflammation of the mucosa of the small intestine, can occur after ileostomy or ileo-anal anastomosis procedures. Gastroenterologists typically prescribe antibiotics like metronidazole (Flagyl) when a patient develops pouchitis.

For standard cases of pouchitis, use the ICD-9 code 558.9 (Other and unspecified noninfectious gastroenteritis and colitis). If the pouchitis is infectious, however, report 558.9 and 997.4 (Complications affecting specified body system, not elsewhere classified; digestive system complications).

Tip: Fortify your claim with documentation that substantiates pouchitis. Some of the symptoms of the condition include:

 abnormal number of stools in one day
 rectal bleeding
 urgency before bowel movements
 fever
 abdominal cramping.

If your patient has any of these symptoms, be sure to note it on your claim.
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