Gastroenterology Coding Alert

Question: A new patient reports to the gastroenterologist complaining of rectal pain. Encounter notes indicate that during a level-two E/M, the gastroenterologist discovers that the patient reopened a sphincter tear that he suffered two years ago. Do I need to include diagnoses for the patient's presenting pain and the old tear?

Idaho Subscriber

Answer: Since the physician reached a diagnosis during the encounter, you do not need to include 569.42 (Anal or rectal pain) for this patient. On the claim, report the following:

• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making ...) for the E/M

• 569.43 (Anal sphincter tear [healed] [old]) for the patient's condition.

Don't stop there: The descriptor beneath 569.43 states "Use additional code for any associated fecal incontinence." So go back and check the encounter notes; if the gastroenterologist indicated fecal incontinence, include 787.6 (Incontinence of feces) as a secondary diagnosis.