Gastroenterology Coding Alert

Question: Our gastroenterologist had an initial consult with a new patient who suffered upper abdominal pain and diarrhea. The provider suspects Crohn’s disease and has ordered more testing. How should I report this?

Arkansas Subscriber

Answer: Until testing or diagnostic services confirm the Crohn’s diagnosis, you should rely on signs and symptoms to justify medical necessity for any services the physician provides. This patient is exhibiting typical signs and symptoms indicative of Crohn’s disease, which you’d code to R10.10 (Upper abdominal pain, unspecified) and R19.7 (Diarrhea, unspecified). However, there is no definitive diagnosis, and these are symptoms that could point to a host of other GI problems. For these reasons, you should not submit a diagnosis code such as K50.90 (Crohn’s disease, unspecified, without complications).

EHR alert: Many electronic health record (EHR) systems will automatically pull any diagnoses that were used during the encounter and place them into the assessment and plan (A/P) sections of the medical record. This includes screening codes or other diagnoses that will be used for future testing. Systems might also suggest codes when a provider is filling out the record. This can lead to providers selecting inappropriate codes if they aren’t educated on guidelines or proper usage. Be sure to keep an open line of communication open and query your provider if ever you have questions.