Pediatric Coding Alert

Learn when and when not to report constipation.

Constipation is a common pediatric condition. When left untreated, it can lead to more severe problems such as rectal prolapse. It can also be a sign of a more severe condition such as Crohn’s disease. However, constipation in children is usually temporary and can be treated without the intervention of a specialist.

Even though it’s common and treatable, constipation is not always easy to code properly. Keep reading for tips on how to submit clean constipation claims.

Review the Constipation Codes

To report pediatric constipation, you’ll usually select from the following K59.0- (Constipation) codes:

• K59.00 (Constipation, unspecified)
• K59.01 (Slow transit constipation)
• K59.02 (Outlet dysfunction constipation)
• K59.03 (Drug induced constipation)
• K59.04 (Chronic idiopathic constipation); includes functional constipation
• K59.09 (Other constipation); includes chronic constipation

Separate the Symptoms From the Diagnosis

While constipation is a diagnosis, it can also be a symptom. “It’s important to therefore first recognize if the provider is describing a symptom or diagnosing the patient definitively,” says Chelsea Kemp, RHIT, CCS, COC, CDEO, CPMA, CRC, CCC, CEDC, CGIC, AAPC Approved Instructor, outpatient coding educator/ auditor for Yale New Haven Health in New Haven, Connecticut. In fact, proper coding will require you look carefully at not only the pediatrician’s notes but also the ICD-10 notes next to each reportable code.

Symptoms: A pediatrician might determine a patient is constipated based on symptoms, but that might not be the best ICD-10 code to report for that encounter. For example, if a patient’s parent explains that their child has not had a bowel movement in five days and is feeling bloated, gassy, and nauseated, this can get tricky. Constipation, even if documented, certainly seems like the obvious diagnosis; but it’s not as simple as that.

A few symptom codes are straightforward, such as R14.0 (Abdominal distension (gaseous)), R14.3 (Flatulence), and R11.0 (Nausea). However, you also need to report R19.4 (Change in bowel habit) to account for the five days without a bowel movement. Notice the Excludes1 notes under R19.4. It says that K95.0- and R19.4 can’t be coded together. “I favor coding the changes in bowel habits for this case since the presenting problem is documented as not having a bowel movement in five days,” Kemp says.

Diagnosis: In situations where constipation is the definitive diagnosis, the initial visit may not provide enough details to report constipation beyond the specificity of K59.00. However, subsequent visits could help the pediatrician come to more detailed diagnoses that also include a plan to manage the condition. For example, many pediatric cases are diagnosed with K59.04. This code includes functional constipation where there is no organic cause. However, a diagnosis of K59.01 might come with the physician’s recommendation that the patient start an over-the-counter (OTC) laxative or a change in diet to see if that helps symptoms.

Coding alert: If the provider determines the constipation to be the result of medication, report K59.03. Be sure to heed the note that says “Use additional code for adverse effect, if applicable, to identify (T36-T50 with 5th or 6th character 5).”

Avoid Getting Stuck on Excludes1 Notes

As is the case with R19.4 and K95.-, several other related codes list Excludes1 notes that are worth keeping an eye out for. The pediatrician may diagnose a patient as being constipated, but after a digital rectal exam and abdominal X-ray discover the patient is suffering fecal impaction. This condition often requires intervention and is a result of severe constipation that causes feces to back up inside the colon. However, the Excludes1 note for K56.41 (Fecal impaction) instructs you not to code K59.0- or R15.0 (Incomplete defecation), and vice versa. This means that even if the pediatrician includes constipation in their notes, you will need to leave that off the claim in favor of the more severe condition, which is the fecal impaction.

Documentation Is the Key to Justifying E/M Level

When reporting the evaluation and management (E/M) code for constipation-related encounters, remember to supply the payer with as complete a picture as possible so they can understand why a seemingly simple diagnosis might have required extensive expertise or time.

For example, let’s say the provider does a full workup and runs several lab tests and it turns out constipation is the final diagnosis.  

If the E/M service doesn’t bring this encounter to a level-four based on medical decision making (MDM), time probably will. If you report 99214 (Office or other outpatient visit for the evaluation and management of an established patient… 30-39 minutes of total time) and pair it with K59.00 as the diagnosis code, that alone might not be enough to justify that level-four E/M service.

However, if you submit as many details as are available, including the conversations with the parent, the thorough exam with tests, and a plan for management, the payer will more clearly understand how the pediatrician spent those 30 to 39 minutes. Also, remember that “if the provider utilizes total time instead of MDM, they should document total time they spent face-to-face with the patient, parent/guardian, and non-face-to-face-time on the date of the encounter,” says Keisha Wilson, CCS, CPC, SPMA, CRC, CPB, AAPC Approved Instructor at KW Advanced Consulting, LLC in Brooklyn, New York. It will also help to include other applicable symptoms in this case, such as R10.30 (Lower abdominal pain, unspecified) and R11.0 (Nausea).